Fillable CHANGE OF INFORMATION FORM (California Polytechnic State University, Pomona)

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CHANGE OF INFORMATION FORM (California Polytechnic State University, Pomona)

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File type: PDF

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March 2020, Registrar’s Office
CALIFORNIA STATE POLYTECHNIC UNIVERSITY, POMONA
Registrar’s Office
CHANGE OF INFORMATION FORM
INSTRUCTIONS: To request an official name, social security number, birthdate change, contact information changes, complete and sign this form. Submit
the completed form to the Registrar’s Office along with official documentation substantiating the requested change. Examples of substantiating
documentation including but are not limited to a copy of a government-issued identification card, marriage license, divorce decree, or other court document.
Please allow 7 to 10 business days for processing. Upload the Change of Information form along with copies of supporting documentation by using our
secure file upload system: Click here to access the link.
Active student may update their personal information including Address, phone number, Preferred name, and email address via BroncoDirect..
Check the box you want to make the change
Primary Name Change SSN Update Contact Information Update (phone number, email, address)
Birthdate Update Gender
Current Name Listed on CPP Records:
First Name:
Middle Name:
Last Name:
Bronco ID:
CPP e-mail:
@cpp.edu
Phone:
Check the Box Next to the Information to be Changed:
Legal/Primary Name Change: Check Reason for Change and Provide Legal Documentation: Effective Date:
Marriage/Divorce Naturalization Legal Name Change Correction of Error Other (Please Specify):
First Name:
Middle Name:
Last Name:
Social Security Number: Check Reason for Change and Provide a copy of your Social Security or Taxpayer ID card
Contact Student Account and Financial Aid to discuss the impact of the change.
Correction of Error New Social Security Number New Taxpayer ID Number
Check this box if you are an International student and wish to receive a 1098T tax form. You must also provide your SSN or ITIN.
Current Number on Record: New Number:
Date of Birth: Provide a copy of your current Driver’s License, State ID, or Birth Certificate. / /
Month Day Year
Change of Citizenship: Provide proof of citizenship (Certificate of Naturalization, Passport, Certificate of U.S. Citizenship)
Gender: Female Male Non-binary/Third Gender Prefer to self-describe Prefer not to disclose
Personal Email Update: New Email Address:
Phone Number Update: New Phone#: _________________
Address Update: New Address: ____________________________________________________________________
Street City State Zip Code county
I certify that I am not employed by ANY organization at Cal Poly Pomona.
STUDENT SIGNATURE:
DATE:
FOR OFFICE USE ONLY
Date Received: Processed By:
Preferred Name: Student Group Code (CRN) added in PS
Yes
Proof: Marriage License State/Federal ID
Other:
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CHANGE OF INFORMATION FORM (California Polytechnic State University, Pomona)

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Completed 28 January 2021

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