Change Personal Information

Change of Name, Birth Date, or Student ID Number -------PDF Form


Printing and Delivery - In order to petition for a change of name, birth date, or student ID number, please complete this form. You can type your information on the form and then print it. Copies of TWO pieces of supporting documentation are required: 1) new SS card, marriage certificate, or court decree of name change, AND 2) new driver's license or state ID.

Requested Change

Name Birth Date Student ID Number

Year in Med School

MS I MS II MS IIIMS IV

New Name

First    
Middle
Last    

Former Name

Current ID #

New ID #

Reason for name change


Marital Status

Single Married   (Used for summary reporting only)

Correct birth date

How can we reach you if we have questions:
E-mail Address:
Daytime Phone:
 

Student Signature

_________________________________________________

Date

Special Note:

If you are or have ever been employed by Indiana University, even as a work-study employee, please provide documentation, such as a photocopy of your driver’s license. If you are or were an IU employee and your marital status has changed, please provide a copy of appropriate documentation. This will be used in adjusting any employee benefits. Contact Human Resources with any questions.
   
   
Mail or bring the completed form to the address below.
Medical Student Education - Student Affairs
IU School of Medicine
635 Barnhill Drive, MS 158
Indianapolis, Indiana 46202
   

*If you wish to have the name on your e-mail address changed, you must contact the UITS Support Center. You need to take proof of your name change and put in a request with them. You can contact them at 274-4357.

   
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