[Text Only Version]
NAME CHANGE AFFIDAVIT (Please Print)
Former Name: ____________________________________________________________________________ First Middle Last |
Social Security Number or Student ID Number ___________________________________________________ |
Name as you Wish it to appear: _______________________________________________________________ First Middle Last |
Last Semester Attended SECC: ____________________ Date of Birth: ______________________________ |
| Reason for Name Change (Please Check): |
Name Changed by Divorce |
I intend to continue to use the name of _______________________________________________ consistently and I have not adopted this name for any fraudulent purpose. |
Signature: __________________________________ Date: _________________ |
| You must attach a copy of documentation which shows the "new" name as you wish it to appear on your official records. (i.e. marriage certificate, driver's license, etc.) |
| INSTRUCTIONS: (1) Print a copy of this form (2) Complete all requested information (3) Attach all required documentation (4) Sign form (5) Return to: Registrar's Office Rm. 111, Newman Hall Southeast Kentucky Community & Technical College 700 College Road Cumberland, KY 40823 |