Office of the Registrar

Name Change Form
Mail to: UNC at Pembroke Office of the Registrar P.O. Box 1510 Pembroke, NC 28372	or	Fax: 910-521-6328

UNCP ID:_______________________________________________ SSN:________________________________
(optional unless employee)

Current Name:________________________________________________________________________________

New Name:__________________________________________________________________________________
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.

Signature:__________________________________________________Date:_____________________________

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

Routing Information:

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.

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Name Change Form