CHADRON STATE COLLEGE
REQUEST FOR CHANGE OF NAME
STUDENT ID NUMBER: _______________________________________
FORMER NAME: _______________________________________________________________
(Last) (First) (Middle or Initial)
NEW NAME: __________________________________________________________________
(Last) (First) (Middle or Initial)
Is the new name a married name? Y / N
If no, are you resuming your maiden name? Y / N
If yes, would you like your spouse listed as your next of kin? Y / N
If yes, please list spouse’s name and contact information.
Name___________________________________ Address_____________________________
City, ST__________________________________ Phone______________________________
7/09
For office use only:
Batch ___________
SIS ___________
Scr 7 ___________
Paper ___________
Vert ___________
Eval ___________
X-Ref ___________
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