Name Change Form

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Change of Name Request Form

Office of the Registrar
(978) 665-4196
registrar@fitchburgstate.edu

Instructions

Please fill in all required fields and present proof of name change: birth certificate, court order, driver’s license, marriage certificate, passport (with matching I-20 or IAP-66 for international students. International students with F or J visas must present passport and matching I-20 or IAP-66.)

Student Information

Student ID:

Last Four Digits of SSN:

(Student ID is @ followed by eight numbers, found on your OneCard)

Student Name (former)

Last Name:

First Name:

Middle Initial:

Student Name (new)

Last Name:

First Name:

Middle Initial:

Reason For Change:

Are you a current student?

Are you an international student?

Documentation

Check each document that you will upload below.

Birth certificate

Court order

Driver's license

Marriage certificate

Passport (with matching I-20 or IAP for international students)

Upload Documentation

Please upload any supporting documents here.

File 1

File 2

File 3

File 4

Please wait for files to finish uploading