CHANGE OF NAME FORM

 

______________________________  _____________________
Former Name                                                                ID Number
 

_____________________________   ______________________
Name Changed To  (print)                                       Effective Date of Change 
 

_____________________________
 Telephone Number 
 

Are you currently enrolled?                                                                              Yes             No 

Are you currently employed by the university?                                      Yes          No
(If Yes, you must take your new social security card to Human
Resources for processing of payroll information)  

___________________________________    _____________________
Signature                                                                                         Today’s Date  

PLEASE PROVIDE PROOF OF YOUR NAME CHANGE…EXAMPLES INCLUDE A COPY OF LEGAL DOCUMENT ,  YOUR NEW SOCIAL SECURITY CARD, OR DRIVERS LICENSE INDICATING YOUR LEGAL NAME.

Make sure to change your Tower One Card in 221 Cartwright Center

      Check here if you wish to have your campus e-mail address reflect this change  

To officially change your name on UW-La Crosse records,
this form must be completed and returned along with documentation to: 

Records & Registration
UW-La Crosse
1725 State Street
La Crosse, WI  54601