Official Name Change Request Form

OFFICIAL CHANGE OF NAME REQUEST FORMSubmit to Evening MBA and Weekend MBA Programs Office, Gleacher 330RegulationsPlease present documentation (i.e. driver’s license, passport, marriage license) of the correct new name with this form. A notarypublic is on the staff of the program office and will notarize this form and make a photo copy of supporting documentation.International admitted students/students in the Full-Time MBA Program or PhD Program must have their name in their Universityrecord match the names as they appear on their passports. International students wishing to change their names in their Universityrecords should provide government-issued identification corresponding to their new names and should also contact the Office ofInternational Affairs.STUDENT LAST NAME STUDENT FIRST NAME UCIDGraduating this Quarter Evening Student Weekend StudentPlease print name as it currently appears on your student record:__________________________________________________________________________________________________First Middle LastPlease print NEW name:__________________________________________________________________________________________________First Middle LastPlease sign FULL new name (including middle):__________________________________________________________________________________________________SignatureDateBooth Account InformationBooth username• Remains the sameBooth e-mail• A new e-mail account may be requested in the format of First.Last@ChicagoBooth.edu.Please check here if you would like to request a new email.Booth e-mail display name• A new name in the form of Last, First name (preferred) may berequested. Please fill out new preferred display name below._______________________________________Last , First (preferred)Students will be notified in 5 business daysSTAFF REMINDER:Make photo copy of supportingdocumentationFOR OFFICE USE ONLY

Notary Public__________________________________________________________________________________________________SignatureDateNotary Seal:MAKE PHOTO COPY OF ALL SUPPORTINGDOCUMENTATIONFor Office Use OnlyDate Processed: __________ By: __________Updated SAMUpdated Student FileCreated New Mail FolderCreated New Name TentRequested New DisplayName (if applicable)