California State University, Northridge A&R NAME CHANGE
Please PRINT CLEARLY and complete all blanks. Due to computer constraints, only 30 characters may be used for some of our files. Hyphenated last names will be run together. These constraints do not apply to diploma names. PRINT NAME AS IT APPEARS ON YOUR CSUN RECORD: ________________________________________________________ Last First MI STUDENT ID# _________________ SS# _________________________ PRINT NEW NAME: ________________________________________________________ Last First MI DATE OF BIRTH _______________ PHONE # (______) _____________
==================================================================================== 1. Are you currently enrolled at CSUN? 2. Are you currently on student leave? 3. Are you a new (first time) applicant to CSUN? 4. Are you reapplying for admission to CSUN? _____ Yes _____ No _____ Yes _____ No _____ Yes _____ No _____ Yes _____ No
IF YOU HAVE APPLIED FOR GRADUATION, PLEASE ANSWER THE FOLLOWING: 5. Type of Degree: _____ Bachelor’ s _____ Master’ s
6. When do you expect to graduate? ________________ Please file a Change of Graduation Date form if you wish to change this date. PRINT NAME AS YOU WISH IT TO APPEAR ON YOUR DIPLOMA NOTE: Your last name and first name on your diploma must be the same as your current name on records. Your middle name may vary only in length (i.e., if an initial appears as your middle name on record, you may use your full name for diploma purposes). DIPLOMA NAME ONLY ____________________________________________________________________ PLEASE PRINT CLEARLY
==================================================================================== I understand all University academic records and correspondence will reflect the name above. I declare the information provided is true and correct. This change of name will not be used for fraudulent purposes and represents a bona fide change in the sense that it is to be or has been used consistently. I understand this change will not remove former names from the permanent record. Signature ____________________________________________ Date _______________________________