CHANGE of Student Record Information
Provide your name and SCCID# “as they currently appearon your SCC student records
Last First MI SCC ID
Telephone # ___________________ Date of Birth: _______
Please check each item you wish to change & print/type those changes in the spaces provided:
1. Name - Change to: Last First MI
2. Social Security Number* - Change to:
*A SSN change requires that you include a copy of your SSN card for verification along with this form.
3. Address - Change to:
Street City/State/Zip Code
4. Email Address Change to:
5. Telephone Number Change to:
(
)
6. Date of Birth Change to: / /
7. ( ) Verified I.D.
__________ Initials
__________ Date
K12 to Grad or
Grad to K12
For Office Use Only:
Student Signature Date By: ____ Date: _________
A&R_03.14.2019 MA
-
RESET FORM
click to sign
signature
click to edit