Office of the Registrar

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Request a Diploma for yourself

Request a Diploma as a gift

Address/Name Change Form

NOTE: You may print this form, complete it and fax or bring it to the Registrar's office; however, all requests MUST be accompanied by a copy of your identification.

CHECK EACH THAT APPLY: STUDENT ______ EMPLOYEE ________
EMPLOYEES OF THE UNIVERSITY MUST CONTACT HR TO UPDATE THIS INFORMATION

SOCIAL SECURITY NUMBER: ___________________________

NAME (Print): (Last)_________________ (First)________________ (Middle)____________

FORMER NAME(S): _____________________________________

CHANGE MAILING ADDRESS TO: _________________________________

(CITY, STATE, ZIP)_____________________________________

PHONE: ______________________________________________

E-MAIL: ______________________________________________

HAVE YOU APPLIED FOR GRADUATION?  YES   NO

GRADUATION DATE: ___________________________________

DO YOU WANT YOUR NAME CHANGED ON YOUR DIPLOMA?  YES   NO

EMERGENCY CONTACT INFORMATION:

NAME: ________________________________________________

ADDRESS: _____________________________________________

CITY, STATE, ZIP: ______________________________________

PHONE: ______________________________________


SIGNATURE: __________________________________ DATE: ____________

Please remember proper identification. If you are submitting a name change, submit legal documentation.

Missouri Southern State University
Registrar's Office
3950 E. Newman Road
Joplin, MO 64801-1595
FAX (417) 625-3117