This form must be accompanied by proof of change of name, i.e. copy of Marriage Certificate, and signed by a Notary Public. Reason For Change: (select one) Given Name Court Order Marriage Naturalization Divorce Other (specify) Old Name: New Name: Address: Email: Effective date of change: Signature: Date: lllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll Subscribed and sworn to before me on this day of 20 . Notary Signature: (Notary Seal or Stamp) lllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll AFFIDAVIT OF CHANGE OF NAME NOTARY OFFICE USE ONLY SIS AAMC Registration & Student Records 550 1st Avenue, Medical Science Building, Suite G90, NY, NY 10016 Tel: (212) 263-5291 Fax: (212) 263-5264 Email: [email protected] Rev. 11.29.16 Street City State Zip (mm/dd/yyyy) (Name as it will appear on University records) (mm/dd/yyyy) Last First Middle Last First Middle PLEASE RETURN ORIGINAL FORM TO THE ADDRESS BELOW Tel: