| Mail to: UNC at Pembroke
Office of the Registrar
P.O. Box 1510
Pembroke, NC 28372
UNC Pembroke ID:_______________________________________________ SSN:________________________________
(optional unless employee)
First Name Middle Name Last Name
Date of Birth:_________Telephone:________________ Email Address:___________________________________
Statement of Responsibility:
I assure responsibility for the consequences or problems that may occur as a result of this change of my name. There is no intent on my part to defraud the University of North Carolina at Pembroke.
Please note: Employment verification requires a social security card to ensure that the name and social security number on record match the name and number on the social security card.
Check all that apply: Student_______ Faculty________ Staff________ Alumni_______ Friend_______
Please include any other names under which you may have been associated with the University of North Carolina at Pembroke:
Return this form, with proper documentation, to the appropriate office below.
- Faculty and Staff: Human Resources, 347 Lumbee Hall
- Students: Office of the Registrar, 133 Lumbee Hall
- Alumni/Friends: Office of Advancement, 442 Lumbee Hall, PO Box 1510 , Pembroke , NC 28372-1510
- Prospective Students: Undergraduate – Admissions, 224 Lumbee Hall
- Prospective Graduate Students: Graduate Studies, 253 Lumbee Hall
FOR OFFICE USE ONLY
Received by Name: Dept: Date:
Changed by Name: Dept: Date:
Required Documents: (Choose one of the following)
Students: Driver’s License, Social Security Card, Divorce Decree or other Court Document showing name change
Employees: Social Security Card required
- HR to Registrar to Graduate (if needed)
- Graduate to Registrar
- Registrar to Graduate (if needed)
- Alumni to Registrar to Graduate (if needed)
This publication is available in alternative formats upon request.
Please contact Disability Support Services, DF Lowry Building, 521-6695.