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Name Change Request Form

Use this form to officially change your name through SIU School of Medicine.

Instructions: 

OFFICIAL DOCUMENTATION AND VALID IDENTIFICATION MUST BE PRESENTED WITH COMPLETED REQUEST FORM.  Acceptable forms of ID include state issued picture ID and one of the following:  Marriage Certificate; Divorce Decree; Court Order; Birth Certificate.  Submit form to Karla Henebry, Registrar.

Form Download: