Official Name Change Request Form

University of Maryland Maryland Fire and Rescue Institute

Please Note: All forms must be submitted in person at any MFRI regional office or at the College Park headquarters. You must also produce a government-issued photo ID to verify your identity.

Instructions: Please complete the form legibly. All supporting documentation must be original. Photocopies or facsimiles will not be accepted. Failure to provide the required information will result in a processing delay or a rejection of the request.

Any one of the following original documents may be used to support the name change request.

 Government-issued Driver’s License  Government-issued ID card  Government-issued Passport  Court Order  Marriage License

Previous Name:

Last Name First Name Middle Name/Initial

New Name:

Last Name First Name Middle Name/Initial

By signing this form, I affirm that I intend to use the new name indicated above consistently, and I have not adopted this name for any fraudulent purpose or to interfere with the rights of others.

Student Signature: Date:

For Official Use Only

Select the original document provided to support the name change request:

o Government-issued Driver’s License o Government-issued ID card o Government-issued Passport o Court Order o Marriage License

By signing this form, I affirm that I have verified the identity of the student and the original document supplied to support the name change request.

Regional Office Representation:

Signature Date