date entered
Houston Community College
Change of name, address, phone, & social security no.
social security no.
CURRENT name
last
Change of: (check all appropriate)
❏ name
❏ phone
first
❏ address
❏ *social security no.
social security change
name
last
first
m.i.
Address change
phone change
new Home address
no.
street
new Home phone
apt. no.
city
in what school district do you reside? ❏ hisd
❏ cy-fair
❏ spring branch
state
❏ stafford
❏ alief
zip
❏ katy
❏ fort bend ❏ north forest ❏ other____________
new mailing address
*to be made only by registrar’s office
PREVIOUS NAME
incorrect S.S. no.
m.i.
no.
street
new permanent phone
apt. no.
city
state
(area code)
(area code)
new work phone
zip
* if your new address changes your residency status, you must complete a Change of Residency petition and submit supporting
documentation
E-mail address
(area code)
With few exceptions, state law gives you the right to request, receive, review and correct information about yourself collected on this form.
Form no. 400 (rev.5/06)
signature
(extension)
date