LEGAL NAME CHANGE REQUEST FORM
Admission and Records
Email: welcome@cocc.edu
Phone: (541) 383-7500
Fax: (541) 318-3700
2600 NW College Way
•
Bend, Oregon 97703
COCC ID Number:
Phone number:
Change Name FROM:
Last: First: Middle:
Change Name TO:
Last: First: Middle:
Reason:
Please attach a copy of the front and back of your government/tribe issued photo ID with your new name and either
your social security card with your new name or a copy of a court judgement establishing the new name.
This form and attachments can be submitted either in person to Enrollment Services at any COCC Campus, via fax
(5
4
1
-
31
8
-
370
0
)
or v
ia
email
(w
elco
m
e
@
co
cc.e
d
u
).
Check here if you are (or were) employed by Central Oregon Community College
Check here if you would like your email address changed to reflect the above name change and understand
the following:
• Your current email address w
ill terminate and it is your responsibility to inform all contacts of this change.
•
All information and data from your previous email address will remain in the account. If you see any
problems in your
COCC email account (missing files, etc.), it is your responsibility to work with a lab
attendant in a COCC Drop- In Lab to resolve these situations.
•
COCC
Admissions will contact you via phone and letter once the email change has been made. Please
allow7-
1
0
busi
n
e
ss
day
s
.
Check here if you would
not
like your COCC email address changed to reflect the above name change. It is your
responsibility to
inform your instructors if your email address does not match your new name on rosters and/or
in Blackboard.
Your signature below attests that your request is valid and that you have read and understand the above information.
Student Signature Date
Rev 9/19
click to sign
signature
click to edit
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