MTSU Records & Scheduling | Middle Tennessee State University

Name Change Request
Registrar's Office - Middle Tennessee State University - Murfreesboro

It is requested that my name on my records at MTSU be changed as follows:

*If you have filed an Intent to Graduate form and wish to change your name on your diploma, you must call 898-5926 or come to the Registrar's Office, Cope 102, and state specifically that you want to change the name on your diploma.

Present name
	(last)	(first)	(middle)

MTSU ID (M#): Are you currently enrolled? Yes No

Former name
	(last)		(first)		(middle)

Note any other names under which your record might be filed

I certify that I intend to use this name consistently and I am not changing my name for fraudulent purposes.

Date: Signature: ________________________________________

FOR OFFICE USE ONLY:

Computer file _____________________________ Cross-reference cards _________________

Permanent record __________________________ Folder _____________________________

AR020-0302

PRINT THIS FORM AND MAIL OR FAX OR RETURN TO COPE 106

Records Office, Middle Tennessee State University, Murfreesboro, TN 37132
Fax: 615-898-5538, Office: Cope Administration Building 106.

Name Change Request Registrar's Office - Middle Tennessee State University - Murfreesboro

Name Change Request
Registrar's Office - Middle Tennessee State University - Murfreesboro