PIEDMONT COLLEGE
NAME CHANGE REQUEST (please print clearly or type)

Current Name on Student Record: ____________________________________________

Student Number: ___________________________________________________________

Change Name to:

__________________________________________________________________________

Student Signature:___________________________________________________________

Form of Documentation (Must include copy--not original):
___Marriage License
___Divorce Decree 

___Drivers License
___Other: ___________________________________________

Date:_________________

New Address If Applicable (include city and zip code): _________________________________

Have you applied for Graduation? Yes______ No____ 

If yes, how would you like your name to appear on your diploma (if different from your application)?
Please note that diplomas cannot be changed after the application deadline. Also, your diploma cannot be changed due to divorce or marriage later in life.
______________________________________________________________________________

_______________________________________________________________________________

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Office Use Only
Registrar's Office:_____________________________________  Date:_________________

Please complete this form and attach one of the above forms of documentation.
Mail This Form and Document to:
Piedmont College Registrar's Office
PO Box 10
Demorest, GA 30535