Completion of this form will result in a name change on your permanent record for all Longwood offices.

Note:  Documentation  verifying the name change must be provided.  Please attach a copy of your official driver's license, a court document, birth certificate, etc. verifying the name change.

SIGN THE FORM, ATTACH DOCUMENT, AND RETURN TO THE ADDRESS BELOW:
Registration Office
Longwood University
201 High Street
Farmville, VA 23909
(434) 395-2580                                               **   Please Print  **

Student's  Old Name :   _______________________________________________
                                                               Last                                        First                              Middle

Student's  New Name :   _______________________________________________
                                                                 Last                                        First                              Middle

ID Number: _____________________________

                            Address:  _____________________________________________

                                             ______________________________________________
                                                               City                                                  State                                       Zip

Telephone Number:  (        )_______________________________________

Student's Signature: _____________________________________________

                           Date: ____________________________________