CHANGE OF NAME FORM
NAME____________________________________________________________
SOCIAL SECURITY NUMBER_________
______
_________________
DATES OF ATTENDANCE __________________ PROGRAM ATTENDED______________________
DATE OF BIRTH ______________________
This is to certify that I am the student who is/was enrolled in Michigan Jewish Institute under
the name of: (print former name)
NAME ___________________ _______________________________ ___________________
last
first
middle
I now wish my name to appear on my student records* as:
(print your name EXACTLY as you wish it to appear)
NAME ___________________ _______________________________ ___________________
last
first
middle
REASON FOR REQUEST:
___Court Order ___Divorce ___Marriage ___Other
DOCUMENTATION:
I am presenting a copy of one of the following forms of documentation to substantiate my new
name: (check one)
__Marriage License __Driver’s License __Passport __Social Security Card __Court Order #______
SIGNATURE _______________________________ DATE ______________
Notarization: Subscribed and sworn to before me on this _____ day of ____________ / _______
____________________________Notary Public
Print name)
State of _____________________
County of __________________
Acting in the County of _____________________________
My Commission Expires ______________
Signature of Notary ____________________________
* Please note: Only the tabs on folders in which your records are stored will be changed to your
new name along with all future academic records. Your name on all financial records will remain
the same unless we receive a copy of your new social security card with your new name.