02/2019
Folsom Lake College
CHANGE OF DATA FORM
**PLEASE PRINT CLEARLY**
CURRENT STUDENT INFORMATION
Name: ________________________________________________________________ Student ID: __________________
Email: _________________________________________________________________ Phone: (_____) _______________
Semester:
□ Summer □ Fall □ Spring Year: ______________ F-1 Visa Student: □ Yes □ No
All requests require a photo I.D. and any supporting documentation if applicable. Allow 10 business days for processing.
Current and Former Los Rios employees must submit all name or address changes to the FLC Business Services Office.
I hereby authorize the FLC Admissions and Records Office to make the following correction(s) to my record:
COMPLETE ONLY WHAT REQUIRES AN UPDATE TO YOUR RECORD!
□ New Name: ____________________________________________________________________________________________
Last, First, Middle Initial
□ Gender: □ Male □ Female
□ Social Security: _____________________________________________
XXX - XX - XXXX
□ Date of Birth: _____________________________________________
MM/DD/YYYY
□ Phone Number: (_______) _____________________________________
□ Email: _____________________________________________________
□ Address: _____________________________________________________
Street Address
____________________________________________________
City State Zip
□ Emergency (WARN) Phone number: (________)____________________ Accepts Texts? □ Yes □ No
□ Update high school graduation status on record (provide official transcript or official GED results):
I earned a High School Diploma: ____________________________________________________________________
HS Name MM/YYYY State & Country
I earned a GED or equivalent: ______________________________________________________________________
Date Earned State & Country
I did not earn a High School Diploma or equivalent.
Other correction: ________________________________________________________________________________
STUDENT SIGNATURE: DATE:
Received & ID Verified By: _________
Date: _________________________
Change Completed By: ____________
Date: __________________________
If updating your high school grad status:
Should we notify Financial Aid of your status change? □ Yes □ No
Please provide at least two forms of
government issued I.D. (one with new name
& one with old name) with your request OR a
copy of the official name change document
from the court.
For Social Security # Changes:
Please provide copy of SSN card.
If changing your address:
Have you petitioned for graduation recently? □ Yes □ No
If you receive financial aid: You must update your address in your Bank Mobile account.
