Fill and Sign the Name Adult Order 101017 Reviseddocx Form

© 2017 Nevada Supreme Court Order for Adult Name Change Your Name: ________________________ Address: ___________________________ City, State, Zip: _____________________ Phone: ____________________________ Email: ____________________________ Self-Represented Petitioner DISTRICT COURT ______________________ COUNTY, NEVADA In the Matter of the Application of: ___________________________________ (print the old name you do not want anymore) For Change of Name. CASE NO.: ____________________ DEPT: _____________________ ORDER FOR CHANGE OF NAME This Order was submitted (☒ check one)  after a hearing  without a hearing before the above-entitled court, and after a review of the pleadings and papers on file and the testimony given, if any, and good cause appearing therefore: IT IS ORDERED that the name of the Petitioner, who was born on (date of birth) _____________________ in (city) _______________________ (state) ____________________ be legally changed from (old) _____________________ ______________________ _______________________ (first) (middle) (last) to (new) _____________________ ______________________ ______________________ (first) (middle) (last) IT IS FURTHER ORDERED that the Clerk transmit a certified copy of this order to the State Registrar of Vital Statistics. A new birth certificate (☒ check one)  shall  shall not be issued reflecting the name change above. Page 2 of 2 - Order for Adult Name Change (the judge may check this box if applicable)  IT IS FURTHER ORDERED that (if the box is checked) the Clerk transmit a certified copy of this order to the Central Repository for Nevada Records of Criminal History for inclusion in the Petitioner’s record of criminal history. DATED this (day) ______ day of (month) ______________, 20____. ____________________________________ DISTRICT COURT JUDGE Submitted By: (your signature)  _______________________________ (print your name) _______________________________