You are here

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. 

You can fill out the form below and submit it to the SIU School of Medicine Registrar

Form Download: