"Name Change Request" - New Jersey

Name Change Request is a legal document that was released by the New Jersey Department of Education - a government authority operating within New Jersey.

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New Jersey State Department of Education
Office of Certification and Induction
NAME CHANGE REQUEST
In order for your name change request to be processed, this form must be completed in its entirety and
mailed to our office. Incomplete forms will be returned. Concerned with the proliferation of identity
theft, the department now requires submission of multiple forms of identification. Additionally, please
apply on-line for this name change request and pay the fee of $20.00. The on-line application and
payment may be completed at: www.state.nj.us/education/educators/license/tcis
Teacher Certification Information System Tracking Number: _______________________________
A. New Name. Please print your new name as it appears on your Social Security Card
Last Name
First Name
Middle Name/Initial
B. Previous Name. Please print your previous name.
Last Name
First Name
Middle Name/Initial
C.
Has your address changed? Indicate if the address you will enter into Section D is a new address for
you. Circle the correct response.
My address has changed along with my change in name
No
Yes
D. Licensee’s Current Address and Identification Information
Street Address
City
State
Zip
Social Security Number
Date of Birth (mm/dd/yyyy)
E. SUBMISSION OF IDENTIFICATION INFORMATION
The licensee is required to submit no less than three types of identification, including the
mandatory photocopy of an individual’s social security card, on which the licensee’s new name
must appear. Clear and legible photocopies of the card and papers should be attached to this
form.
Once completed, the form and any attachments should be forwarded to: New Jersey State
Department of Education, Office of Certification and Induction, P.O. Box 500, Trenton, New
Jersey, 08625-0500. Attention: Name Change Request.
PLEASE COMPLETE SECTIONS ON NEXT PAGE
1
New Jersey State Department of Education
Office of Certification and Induction
NAME CHANGE REQUEST
In order for your name change request to be processed, this form must be completed in its entirety and
mailed to our office. Incomplete forms will be returned. Concerned with the proliferation of identity
theft, the department now requires submission of multiple forms of identification. Additionally, please
apply on-line for this name change request and pay the fee of $20.00. The on-line application and
payment may be completed at: www.state.nj.us/education/educators/license/tcis
Teacher Certification Information System Tracking Number: _______________________________
A. New Name. Please print your new name as it appears on your Social Security Card
Last Name
First Name
Middle Name/Initial
B. Previous Name. Please print your previous name.
Last Name
First Name
Middle Name/Initial
C.
Has your address changed? Indicate if the address you will enter into Section D is a new address for
you. Circle the correct response.
My address has changed along with my change in name
No
Yes
D. Licensee’s Current Address and Identification Information
Street Address
City
State
Zip
Social Security Number
Date of Birth (mm/dd/yyyy)
E. SUBMISSION OF IDENTIFICATION INFORMATION
The licensee is required to submit no less than three types of identification, including the
mandatory photocopy of an individual’s social security card, on which the licensee’s new name
must appear. Clear and legible photocopies of the card and papers should be attached to this
form.
Once completed, the form and any attachments should be forwarded to: New Jersey State
Department of Education, Office of Certification and Induction, P.O. Box 500, Trenton, New
Jersey, 08625-0500. Attention: Name Change Request.
PLEASE COMPLETE SECTIONS ON NEXT PAGE
1
ACCEPTABLE DOCUMENTATION
Indicate with check-mark if
attached.
COURT ORDER: Or other legal paperwork showing the
official name change MUST be submitted.
SOCIAL SECURITY CARD. A photocopy of the applicant’s
social security card must be submitted as one of three types of
identification for the purpose of changing an individual’s name.
If your card has been lost, a replacement will need to be issued.
To request a replacement card, please contact the Social
REQUIRED
Security Administration at 1-800-772-1213 or go to
http://www.ssa.gov/ssnumber
and click on Replacement Card.
The remaining two items may be selected from the items listed
below. Change requests that do not include a photocopy of the
social security card, will be rejected.
In addition to a copy of the applicant’s social security card, select 2 of the following items for
submission. These forms of ID may appear in either your former or new name.
1 Valid Marriage License
2 Certificate of Birth (Raised Seal Copy)
3 New Jersey or Out-of-State Auto Operator License
4 United States Passport (current or expired within 3 years)
5 Adoption Papers
6 Certificate of Citizenship
7 Certificate of Naturalization
8 United States Military Photo ID Card
9 New Jersey Non-Driver Digital ID Card
F. CERTIFICATION
Responses to the following two questions are mandatory. Failure to complete these items will
result in rejection of the candidate’s application for certification.
Circle which applies below
Have you ever had a certificate revoked or suspended in this or
any state?
Yes
No
Have you ever been convicted of a criminal offense in this or any
other state or any jurisdiction outside of the United States?
Yes
No
Mail this form and your attachments to:
New Jersey State Department of Education
Office of Certification and Induction
P.O. Box 500
Trenton, New Jersey 08625-0500
Attention: Name Change Request
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G. Verification of Accuracy
I certify that all statements and information provided herein are true and accurate.
Applicant’s Signature
Date (mm/dd/yyyy)
Notary Seal
Notary Signature
Sworn to before me this __________________ day of __________________, 20______
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