Change of Name,
Address, Telephone
or Social Security Number
DAYTONA
STATE COLLEGE
Records@DaytonaState.edu
Old Information
Last Name
First Name
Student I.D. / Social Security Number
Middle Initial
Telephone Number
___ ___ ___ - ___ ___ - ___ ___ ___ ___
Street Address
City
State
Zip
New Information
Last Name
First Name
Student I.D. / Social Security Number
Middle Initial
Telephone Number
___ ___ ___ - ___ ___ - ___ ___ ___ ___
Street Address
City
Signature
State
Zip
Date
Name Change: The student must provide both the legal document that initiated the change (marriage license, divorce certificate,
or legal change of name) and his/her identification card/drivers license.
Social Security Number Change: The student must provide both his/her photo identification and social security card.
Office Use Only:
Campus _______________________________________________________________ Date ____________________
Input by _______________________________________________________________ Date ____________________
6754N DSC 3/14