Name/DOB/SSN Change or Correction Request

Name/DOB/SSN Change or Correction Request
Please fill out the information below and present to Enrollment Services with the proper supporting documents. Name changes will not be processed without supporting legal documentation. See chart below for required documentation.

Please check the box(es) of the item(s) that you are requesting to be changed or corrected.

Reason for Change/Correction	Documentation Needed
Marriage	Copy of marriage certificate or signed social security card
Divorce	Copy of divorce decree stating you may resume the use of your maiden name or signed social security card
Legal Name Change	Copy of court documents authorizing name change or signed social security card
Misspelled Name	Signed social security card
Incorrect Date of Birth	Driver's License, State ID, or other official document that shows name and DOB
Incorrect Social Security No.	Copy of signed social security card

Please upload required documents (refer to chart for required documents)

Cancelof
Note: If you are a student who is also employed by the College, changes must be done through Human Resources.
Name of Student:

First NameLast Name
Student ID No (L#):
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Student Email
example@example.com
Check off what you need changed:
NAME - As it Currently Appears:

First NameMiddle NameLast Name
NAME - Correct/Change to the Following:

First NameMiddle NameLast Name
DATE OF BIRTH - As it Currently Appears:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
DATE OF BIRTH - Correct/Change to the Following:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
SOCIAL SECURITY NUMBER - As it Currently Appears:
SOCIAL SECURITY NUMBER - Correct/Change to the Following:
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
FOR OFFICE USE ONLY
Change Processed On:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Processed By:
Copy to FA:
Copy to BO:
Should be Empty:

FOR OFFICE USE ONLY