Directions: Fill out your name and social security number at the top of the page. In the New
Data section fill in any information that you wish to change. Sign at the bottom of the page
and return to the admissions office.
Old Data
Name: _____________________________________ SSN: __ __ __ - __ __ - __ __ __ __
Empl. I.D.: ___ ___ ___ ___ ___ ___ ___
New Data
Change my name to: ________________________________________________
Change my Social Security Number to: ___ ___ ___ - ___ ___ - ___ ___ ___ ___
Change my address to:
______________________________________
______________________________________
Change my phone number to:
Home: (___ ___ ___) - ___ ___ ___ - ___ ___ ___ ___
Work: (___ ___ ___) - ___ ___ ___ - ___ ___ ___ ___
Change my Veterans Educational Benefits eligibility to NO.
I received a High School Diploma or GED from: ____________________________
Date received: ______________________
Change my advisor to: __________________________________
Other Change: ________________________________________________________
Signature: ________________________________________
Date: ____________________
Revised 12/14