University of Southern Queensland
Change of Name
Return this form and documents to:
USQ Graduations Office
West Street
Toowoomba QLD 4350
Phone: +61 7 4631 1647 or +61 7 4631 1741
Email: [email protected]
USQ is collecting the personal information on this Form for university purposes to provide notarisation services. The information may be made
available to Commonwealth and State agencies and the ESOS Assurance Fund Manager pursuant to obligations under the Education Services for
Overseas Students Act 2000 and National Code or other legislative requirements. Personal information will not be disclosed to third parties other
than a USQ approved agent, partner or any organisation who provides sponsorship to you for your studies, without your consent unless required
by law. Your rights to access and amend your personal information are set out in the Information Privacy Act 2009 (Qld) which also places
obligations on USQ as to how we handle your personal information. For further information concerning Privacy, please direct any queries to the
USQ Legal Office.
PERSONAL DETAILS
Student Number:
Graduating:
Date of Birth: DD/MM/YY
Another semester
This semester
ENROLLED NAME
Family Name:
First and Second
Names:
NAME CHANGE REQUESTED
Mr
Mrs
Title:
(enrolment purposes only)
Family Name:
First and Second
Names:
Miss
Ms
Dr
REASON FOR CHANGE OF NAME REQUEST
I changed my name with the Registry of Births, Deaths and
Marriages.
My full name is not reflected on USQ enrolment records.
I am reverting to a former name.
Attach documentation as
evidence.
International students only: Additional names/symbols are to
printed on my testamur (eg s/o, d/o,@). Note: enrolment
records will not be altered
The order of my names, to be printed on my testamur, is
incorrect.(Indicate this name over page on the section
indicated)
In this case the names do
not change only the
order. No documentation
is required.
Other (please indicate)
THE ORDER IN WHICH YOUR NAME SHOULD APPEAR ON YOUR TESTAMUR (CERTIFICATE)
For example:
GRADEXT3
(CRICOS No: 00244B QLD; 02225M NSW; TEQSA PRV12081)
1.
2.
3.
Family, First, Second Name:
First, Second, Family Name:
First, Family Name:
Smith Joseph John
Joseph John Smith
Joseph Smith
Enter Name:
If this testamur name above is left blank, your testamur will show as per your primary enrolled
name.
Documentation as evidence of change of name:
All name change requests must be accompanied by documentation. This may include certified copies of:
- a certificate issued by the Registry of Births, Deaths and Marriages
- a passport
- a drivers licence
- a National Identity Card.
Certification can be issued by a Justice of the Peace or Notary Public.
Certified scanned documentation will be accepted. However, in some instances the University may request
mailing of certified hard copy documentation. Please note, if a name change has been processed and later
found to be made on the basis of fraudulent documentation, the name change will be reversed.
Name change requests will not be processed unless the required documentation is submitted in the format
requested.
Signature:
Date: DD/MM/YY
Office Use
Only:
GRADEXT3
(CRICOS No: 00244B QLD; 02225M NSW; TEQSA PRV12081)
