PRINT the name that is currently on your records at Kirkwood Community College:
First Name: ________________________________________ Middle Name: __________________________________
Last Name: _______________________________________________________________________________________
K number: ____________________ Email address: ____________________________________________________
Address: _________________________________________________________________________________________
City: _________________________________ State: ______ ZIP: ___________ Telephone: ____________________
PRINT the new name you want placed on your records:
First Name: ________________________________________ Middle Name: __________________________________
Last Name: _______________________________________________________________________________________
I hereby represent that all above information is true and accurate.
Signature: ___________________________________________
(Sign in the presence of a Notary Public)
State of _______________________________
County of _____________________________
I hereby certify that on this __________ day of _____________________, 20________
Personally appeared before me the signer and subject of the above form, who signed or attested to the same in my presence, and presented the following form of identification as proof of his or her identity: o Driver’s License or Government Identification Card o U.S. Passport o U.S. Military ID Card o State Identification Card o Social Security Card o Birth Certificate o Other: _______________________________________________________________
(provide description)
Notary Public: __________________________________________
My Commission Expires: _________________________________
Notary Public Signature: __________________________________
Reserved for Notary Seal