Name Change Form
| 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
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
Return this form, with proper documentation, to the appropriate office below.
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
This publication is available in alternative formats upon request.
Please contact Disability Support Services, DF Lowry Building, 521-6695.
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