V-A&R 12-08
Ofce of Admissions & Records
Change of Student Information
PLEASE PRINT CURRENT INFORMATION BELOW
Last Name, First, M.I.
Student ID or Social Security Number Date of Birth (mm/dd/yy)
PLEASE CHECK & COMPLETE ONLY THE AREA(S) TO BE CHANGED:
r Name
Last First M.I. (Verication required)
r Date of Birth ____/____/____ Social Security __________________
r Telephone Home (_____) __________ - ______________ Mobile (_____) __________ - ______________
r Email ____________________________________________________.
r Major (Degree) ____________________________________________
r Address (Legal, NO P.O. Boxes) r Mailing (P.O. Boxes Okay)
Number Street Apt#/Space
City State Zip
Signature Date
(Verication required) (Verication required)
Valley College
San Bernardino
Wyoming
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