ALVIN COMMUNITY COLLEGE
PLEASE PRINT Student Data Change Request
Student ID___________________ ____________________________________________________________________
Last Name First MI
Student SSN__________________ Date of Birth_______/________/_______
Month Day Year
To change or update information currently on file, place a check by the box(es) you wish to change. Fill in the correct
informaiton and provide appropriate documentation where required.
[ ] New name is:___________________________________________________________________________________
Last Name First MI
REASON FOR CHANGE, CHECK ONE [ ] Marriage [ ] Divorce [ ] Court Order [ ] Other_____________________
[ ] New residential/physical address is:
_________________________________________________________________
Street and Number
___________________________|________________|______|_____________
City County State Zip Code
[ ] New mailing address is:
_________________________________________________________________
Street and Number
___________________________|________________|______|_____________
City County State Zip Code
[ ] New personal email address is:_______________________________________
[ ] New Cell phone number: ( )________-________ [ ] New Home phone number: ( )________-________
[ ] New Emergency Contact Person/Phone number:________________________________( )________-________
Last Name First Name
[ ] Social Security Number: ________/________/________ (must show new social security card)
[ ] Birth Date:________/________/________ (must provide proof)
I certify that the informaion provided is true and correct.
______________________________________________ _______________________________
Student Signature Date
Admissions & Registrar’s Office Use Only: Data Changed by __________________________ Date________________
Residency Reclassification required ________Yes _________No Hold Removed ________Yes ________No
Distribution: Student’s Record Rev: 10/2019
NOTE: When the mailing address is out-district and the residential address is in-district, proof of in-district residency will be required. When
both addresses are changed to an out-district address from an in-district address, residency will be changed automatically and the student’s
tuition/fees may be re-billed for the current term. All other residency reclassification petitions must be done by completing a Residency
Reclassification Petition. Without it, your address will be changed, but your residency classification will not.
click to sign
signature
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