Enrollment Services
Records and Registration
One University Drive
Camarillo, CA 93012
Phone: (805) 437-8500
Application for Name Change
or other Campus Personal Information
Student ID
Student's Signature Date
All changes must be accompanied by legal documentation verifying the information being changed such as a social
security card, court documents, or marriage certificate and a photocopy of a photo ID to verify the new name, correct
social security number, or correct date of birth, such as driver's license, passport, or immigration card.
I understand all University academic records and correspondence will reflect the name above. I declare the information provided is true and correct. This change
of name will not be used for fraudulent purposes and represents a bona fide change in the sense that it is to be or has been used consistently. I understand this
change will not remove former names from the permanent record.
Phone:
IMPORTANT NOTICE: If you have ever been employed at the University, your name change must be processed by
Human Resources.
First Name
Middle Name
Last Name
Please indicate the following:
Applicant, not enrolled in classes at CI
Current student, enrolled in classes at CI
Previously enrolled, not currently enrolled in classes at CI
Administrative Use Only-Records & Registration
Processed by _______________ PS Update:______________ Hershey File Update:_____________ Date:____________
(Staff Initials) (Date) (Staff initials)
Work Order Submitted:________________ Student Notification:_________________
(Date) (Date)
G/AR/80/Forms/Records/Student Forms/F09-Application for Name Change/ Revised 12/15/2009
Please select from the following:
Name Change
Social Security Number Correction
Date of Birth Correction
Print Name exactly how it appears on your CSU Channel Islands Record:
Last NameMiddle NameFirst Name
Print New Name (Please note: there is a 30 character limit):
Date
Social Security Number on file Correct Social Security Number
Date of Birth on file Correct Date of Birth
Applied for graduation?
If yes, what is your expected graduation term?
YesNo
**Name changes will be completed approximately by the end of each semester. Students are notified through their dolphin e-mail
when the name change is completed**
