Office of the Registrar

OFFICE OF THE REGISTRAR
THE UNIVERSITY OF NORTH CAROLINA AT PEMBROKE

NAME CHANGE FORM

Directions: Please print, complete and return to the Office of the Registrar.

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

Current Name:________________________________________________________________________________

New Name:___________________________________________________________________________________
First Name Middle Name Last Name

Date of Birth:_________________________________________________________________________________

Daytime 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)

Please return completed form to:

Office of the Registrar
PO Box 1510
Pembroke, NC 28372-1510

Office Location: Lumbee Hall, Room 133

Return to Forms | Office of the Registrar