Name Change Request Form printable pdf download

Name Change Request Form

EMI Independent Study Program

Name Change Request

Please type or write your information legibly

*Please note that your name in our database must also match the name in your FEMA

SID profile in order to process your IS exam(s). Please log in and update your FEMA

SID profile at

https://cdp.dhs.gov/FEMASID

Your Current Information:

Full Name: _____________________________________

Address: _______________________________________

City, State & Zip Code: ___________________________

SSN/FEM SID: __________________________________

Phone Number: __________________________________

Email address: ___________________________________

Previous Information:

Last Name: ___________________

First Name: ___________________

Middle Initial: _____

Reason for change:

__ Divorce/Marriage

__ Legal Name Change

__ Other

Signature _______________________Date: ____________

MAIL YOUR REQUEST TO

National Emergency Training Center

EMI Independent Study Program

16825 South Seton Avenue

Emmitsburg, MD 21727-8998

FAX TO: (301) 447-1201

Rev 9/15/16

Name Change Request Form