Affidavit Of Change Of Name - NYU Langone Health · Notary Signature: (Notary Seal or Stamp)...

This form must be accompanied by proof of change of name, i.e. copy of Marriage Certificate, and signed by a Notary Public.

Reason For Change: (select one) Given Name

Court Order

Marriage

Naturalization

Divorce

Other (specify)

Old Name:

New Name:

Address: Email:

Effective date of change:

Signature: Date:

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Subscribed and sworn to before me on this day of 20 .

Notary Signature:

(Notary Seal or Stamp)

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AFFIDAVIT OF CHANGE OF NAME

NOTARY

OFFICE USE ONLYSIS AAMC

Registration & Student Records 550 1st Avenue, Medical Science Building, Suite G90, NY, NY 10016 Tel: (212) 263-5291 Fax: (212) 263-5264 Email: Carmen.Vera@nyumc.org

Rev. 11.29.16

Street

City State Zip

(mm/dd/yyyy)(Name as it will appear on University records)

(mm/dd/yyyy)

Last First Middle

Last First Middle

PLEASE RETURN ORIGINAL FORM TO THE ADDRESS BELOW

Tel: