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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: [email protected]
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:
