Name or Social Security Number
Change
Who needs to use this form?
Important Notes
Gateway Student Services
700 East Seventh Street
Saint Paul, Minnesota 55106-5000
E-mail: [email protected]
Phone: 651-793-1300
How to Submit
• If you are an active student, you will need All students must complete sections 1 and 4.
a new student account. IT will
Complete section 2 for a name change, and
be contacted on your behalf, and they
section 3 for a social security number change.
will follow up with you.
Submit this form, along with legal
• Metropolitan State University reserves
documentation, to the Gateway Student
the right to request more than one
Services Center by mail or in-person.
form of documentation for verification
purposes.
Current and former students who wish
to declare a legal name or social security
number change.
Section 1 - Current Student Information
Print current name:________________________________________ ________________________________________ _____________________
Last
First Middle
Metropolitan State student ID: ___ ___ ___ ___ ___ ___ ___ ___
E-mail address: ___________________@_________________________
If you are a current student of Metropolitan State, use your student e-mail address
Phone (with area code): ______-______-_____________
Are you a U.S. citizen?
o Yes o No
Birth Date: _____ / _____ / _______
MM
DD
YYYY
If no: type of visa: o F1 o Other ________
Staff: Check with International Student Services
Section 2 - Name Change
Select one:
q Change display name only; display name changes will impact the name you and/or others see via the portal, D2L, email, class rosters, and official
records.
q Change username and display name; username changes will impact how you log into the portal, D2L, and email along with changing the name you
and/or others see via the portal, D2L, email, class rosters, and official records.
q Make no technology changes; everything will remain as is except for the impact to official records.
Effective date: ____ / ____ / ______
MM
DD YYYY
q I have included a copy of legal documentation of this change.
Examples include: birth certificate, marriage license, court order, naturalization document, divorce
decree (please include only pages indicating name change).
Print new name:___________________________________________ ________________________________________ _____________________
Last
First Middle
Section 3 - Social Security Number Change
Effective date: ____ / ____ / ______
MM
DD YYYY
q I have included copies of my new social security card and a photo ID.
New social security number: ___ ___ ___ - ___ ___ - ___ ___ ___ ___
Section 4 - Signature
I request and authorize Metropolitan State University to change my university record using the included legal documentation.
Signature: ______________________________________________________________________________________ Date: ____ / ____ / ______
MM DD YYYY
An equal opportunity educator and employer
Member of the Minnesota State Colleges & Universities (MnSCU) system
Last updated 04/2012