Change Of Name Form - Clark University
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1Office of the University Registrar
950 Main Street
Worcester, MA 01610
508-793-7426
registrar@clarku.edu
Clark University allows current students to change the name on their academic record for the following
reasons: marriage, divorce, legal name change, or correction of an error. All requests must be
accompanied by the student’s Clark OneCard as well as one of the following forms of documentation for
verification of the legal name change:
Social Security Card issued in new name
•
Birth Certificate
•
Marriage Certificate
•
Divorce Decree
•
Legal Name Court Order
•
Valid passport
•
nd
Please complete items A-E below and return the completed request form to the Registrar's Office, 155 Woodland Street, 2
Floor
(formerly 18 Downing Street).
A. Clark University ID#:
_____________________________
B. Current Name on Record:
Please print the name that currently appears on your Clark University academic record.
________________________________ ____________________________ _________________
Last Name
First Name
Middle Name/Initial
C. New or Corrected Name:
Please print the name that you would like to appear on your Clark University academic record.
________________________________ ____________________________ _________________
Last Name
First Name
Middle Name/Initial
D. Reason for Change:
Please check one.
Marriage or Divorce
Legal Name Change
Correction of Error
Other:
___________________
E. Signature
Please sign below to authorize your name change on your academic record.
______________________________________________________
Signature of Student
________________
Date
Note: The official name on an academic record cannot be changed after a student has graduated or is no longer
enrolled at Clark University. The name that appears in the system is the name that will appear on your diploma and
any other official document that may be issued by Clark University.
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Parent category: Legal