Registrar

Name Change Form

 
Mail to: UNC at Pembroke
              Office of the Registrar
              P.O. Box 1510
              Pembroke, NC 28372
or Fax:  910-521-6328

UNC Pembroke ID:_______________________________________________ SSN:________________________________
                                                                                                                      (optional unless employee)

Current Name:________________________________________________________________________________

New Name:__________________________________________________________________________________
                   First Name                                  Middle Name                                          Last Name

Date of Birth:_________Telephone:________________ Email Address:___________________________________

Statement of Responsibility:

I assure responsibility for the consequences or problems that may occur as a result of this change of my name.  There is no intent on my part to defraud the University of North Carolina at Pembroke.

Please note:  Employment verification requires a social security card to ensure that the name and social security number on record match the name and number on the social security card.

Signature:­__________________________________________________Date:_____________________________

Check all that apply:  Student_______  Faculty________ Staff________ Alumni_______ Friend_______

Please include any other names under which you may have been associated with the University of North Carolina at Pembroke:

Return this form, with proper documentation, to the appropriate office below.

  • Faculty and Staff:  Human Resources, 347 Lumbee Hall
  • Students:  Office of the Registrar, 133 Lumbee Hall
  • Alumni/Friends:  Office of Advancement, 442 Lumbee Hall, PO Box 1510 , Pembroke , NC 28372-1510
  • Prospective Students:  Undergraduate – Admissions, 224 Lumbee Hall
  • Prospective Graduate Students:  Graduate Studies, 253 Lumbee Hall
 

FOR OFFICE USE ONLY

Received by  Name:                                          Dept:                                     Date:

Changed by   Name:                                          Dept:                                     Date:

Required Documents:  (Choose one of the following)

Students:  Driver’s License, Social Security Card, Divorce Decree or other Court Document showing name change

Employees:  Social Security Card required

Routing Information:

  • HR to Registrar to Graduate (if needed)
  • Graduate to Registrar
  • Registrar to Graduate (if needed)
  • Alumni to Registrar to Graduate (if needed)

This publication is available in alternative formats upon request. 
Please contact Disability Support Services, DF Lowry Building, 521-6695.