Change of Name Request Form

Student Information

Former Name * Former Name exactly as it appears on your previous Social Security card. (Please attach a copy)

Please enter the student's former full name.

Last 4 digits of SSN *

Last 4 digits of SSN are required.

New Name * New Name exactly as it appears on your current Social Security card. (Please attach a copy)

Please enter the student's full name.

Date *

Date is required.

Document Type

Please include front and back of your personal document.

Attachment Document

Selecting a file will upload it automatically.

Attachment Former SSN Card

Selecting a file will upload it automatically.

Attachment New SSN Card

Selecting a file will upload it automatically.

Student Email *

Enter a valid email address (e.g., name@example.com).

The school will notify you when the updated diploma/certificate is ready.

Mobile Number *

Valid phone number required.

Address *

Please enter a valid street address.

Country *

City *

City must contain letters only (min 2 characters).

State *

Use 2-letter state code (e.g., NY).

Zip Code *

Use a 5-digit ZIP code.

Program Details

Training Program Name *

Training Program Name is required.

Date Completed *

Please select the completion date.

Student ID# (optional)

Certification # (optional)

Home Care Registry # (optional)

Reason for Change of Name Request *

Marriage Divorce Certificate of Naturalization showing a new name Court order name change Case of Order # New Identity Correcting errors on my Social Security Card Correcting errors on my First Name Social Security Card Correcting errors on my Last Name Social Security Card

Please select exactly one reason.

Once the information is verified, the school will issue an original duplicate certificate or diploma within 30 days of the request date.

Verification & Signature

Student Signature (type full name) *

Please type your full name. Typing your name is the legal equivalent of your handwritten signature.

By typing your full name, you agree this is the legal equivalent of your handwritten signature.

Date *

Date is required.