G:\REGSTRAR\FORMS\Change of Name.doc
8/3/2007
CHANGE OF NAME
VALPARAISO UNIVERSITY
Office of the Registrar
1700 Chapel Dr. – Kretzmann Hall
Valparaiso, IN 46383
(219) 464-5212
Date: ________________________ VU ID #: _______________________
Birth date: ______________________________ Social Security Number: _______-_______-_______
Current Email Address: ________________________________________________________________
Former Name:
___________________________________________________________________________
Please Print Last
First
Middle
Former Marital Status: (please check one)
Single ___ Married ___ Divorced ___ Widowed ___ Separated ___
Current Name:
___________________________________________________________________________
Please Print Last
First
Middle
Current Marital Status: (please check one)
Single ___ Married ___ Divorced ___ Widowed ___ Separated ___
Documented proof (marriage certificate or court documentation) is required.
Documentation Provided: ___________________________________________________________
_________________________________________________________________________________
Signature: ___________________________________________________________