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Admissions and Records
Request for Change of Student Information File
Student Name
Social Security Number
Please change the following item(s) in my student records:
 CHANGE OF PROGRAM (MAJOR):
From: __________________________________
To: __________________________________________
EfectiveTerm:
 Please note: If you are making a program change, your catalog year will be the catalog in effect at the time of change. If a
program correction is required, please come to the Admissions & Records Office.
 CHANGE OF ADDRESS:
New Street Address:
Street
ci ty
State
'Lip
New Mailing Address: _______________________________________________________________
Mailing
City
State
Zip
 Please note: If changing from out-of-district/out-of-state to in-District, you MUST fill out the REQUEST FOR CKANGE OF
RESIDENCY STATUS form.
 CHANGE OF EMAIL ADDRESS:
 CHANGE OF TELEPHONE NUMBER:
Home: ______________________ Work: ____________________ Cell:
 CORRECTION OF SOCIAL SECURITY NUMBER:
As it now appears on File: ___________
Correct Number:
• Please note: Change of Social Security Number requires a copy of your Social Security Card.
 NAME CHANGE: Frotn: _______________________
To:
• Please note: For a name change, you must complete the AFFIDAVIT FOR NAME CHANGE form and provide the
approved documentation as required by the college. Approved documentation includes: marriage license, divorce
decree, court order, or a social security card.
I certify that the information I have given on this form is true and correct to the best of my knowledge.
Signature of Student
For College Use Only Updated by: _________________________________
Date
Date: