Information Change Form
Forms sent electronically from a non-student email account or if required supporting documentation is missing your request will not be processed.
CCC ID Number:
First Name Middle Initial Last Name
Telephone Number: Email Address:
Currently Enrolled:
Yes
No
Check each category that applies:
Name Update (Option Only for Currently Enrolled Students)
Previous Legal First, Middle, Last Name on Record:
Updated First, Middle, Last Name:
Supporting Documentation Required (Original or certified copy of one of following):
• Government Issued ID (driver license, state ID card, valid passport)
• Birth Certificate
• Court Order/ Divorce Decree (must show change to new name)/ Marriage Certificate
• Certificate of Naturalization/ Permanent Resi
dent Card/ Visa
Note: Documentation is not required to add/delete hyphen, space, apostrophe, or to abbreviate a middle name to initial.
Social Security Number Update
Previous Social Security Number:
Updated Social Security Number:
Supporting Documentation Required:
Updated, signed Social Security Card
Emergency Contact Update (other contacts will be removed from student account)
First Name Last Name Relationship
Supporting Documentation Required:
• Government Issued ID (driver license, state ID card, valid passport)
Revised Birth Certificate
Use of the legal name will continue to be required for certain documents, including but not limited to, payroll records, billing records, financial aid documents, official
transcripts, diplomas, medical records, and federal immigration documents. When this name change is complete, changes will be made to your Pathway user name,
your student email address, your Canvas user name, and all other user names that are generated based on your name. Your student ID number will remain the same.
________________________________
______________________________________________________
Student Signature
Date
Admissions & Records Office • 417 Schepps Blvd• Clovis, NM 88101
(575)769-4025•admissions@clovis.edu
Updated: 02/21/2020
C00
Address (if different from student)
Phone Number
My signature certifies that this request is accurate and not intended for fraudulent purposes.
Student Information
Address (Street, City, State, Zip):
Yes No
Is this an updated address?
click to sign
signature
click to edit
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