Change of Name

Change of Name, Birth Date, or Student ID Number

Printing and Delivery - In order to petition for a change of name, birth date, or student ID number, you must complete this form. We ask that you type your information on the form and then print it. Required supporting documentation is either an updated driver's license, court decree of name change, or a copy of a marriage license.

Requested Change	Name Birth Date Student ID Number
Year in Med School	MS I MS II MS IIIMS IV
New Name	First Middle Last
Former Name
Current ID #
New ID #
Reason for name change
Marital Status	Single Married (Used for summary reporting only)
Correct birth date
How can we reach you if we have questions:
E-mail Address:
Daytime Phone:

Student Signature	_________________________________________________
Date
Special Note:	If you are or have ever been employed by Indiana University, even as a work-study employee, please provide documentation, such as a photocopy of your driver’s license. If you are or were an IU employee and your marital status has changed, please provide a copy of appropriate documentation. This will be used in adjusting any employee benefits. Contact Human Resources with any questions.



	Mail or bring the completed form to the address below.
	Medical Student Affairs IU School of Medicine 635 Barnhill Drive, MS 124 Indianapolis, Indiana 46202

*If you wish to have the name on your e-mail address changed, you must contact the UITS Support Center. You need to take proof of your name change and put in a request with them. You can contact them at 274-4357.