Office of the New Brunswick Registrar, Administrative Services Building
       Proctor Hall, 65 Davidson Road - Room 207, Piscataway, NJ 08854

 CHANGE OF NAME FORM - (Please Print)

Read the “Policy Statement on Student Name Changes on University Records” before completing this form.  Use it only to change your name on the University’s records, not to correct or adjust the spelling or format of your name. Two forms of identification are required.

1.  Current (Old) Name: _________________________________________________________________________
     (in computer now)                  Last                                              First                                 Middle Name or Initial

     Requested (New) Name: _______________________________________________________________________
     (name changed to)                  Last                                              First                                 Middle Name or Initial

     Student RUID Number: ________________________________      Telephone #____________________________

2.  If currently enrolled, complete the following:

      Current School /College Attending: ___________________________________________

      Other Rutgers Schools of Attendance: _________________________________________

3.  If not currently enrolled, complete the following:      Date of Birth: _____________________

      Last School of Attendance:___________________________________________________

      Other Rutgers Schools of Attendance:_______________________________________________

      Degree(s) Awarded and Year(s) Awarded:______________________________________________

4.  I submit __________________________ and __________________________ (a copy of your driver's license, voter registration
     card, marriage license, bank document, court order, social security card, etc.) to verify my name change.

5.    STATEMENT BY STUDENT:

        I affirm that the request for a change of name on the Rutgers University Registrar’s Student Records has no
        fraudulent or criminal purpose.

        __________________________________________________            __________________________
                                  Signature                                                                         Date
= = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = =
                                                                                    For Registrar’s Office Use Only                                                                     Revised 1/26/06

Maintenance completed:_________________________                                 Permanent Record Card corrected:_______________________
                                                  Date                                                                                                                        Date
cc:    Dean of Students – Active Students Only                              Financial Aid Office – Active Students Only
        Dean of College/School – Active Students Only                     Business/Cashier Office – Active Students Only
        Alumni/Alumae Office – Degree Holders Only