Fillable NAME/ADDRESS CHANGE REQUEST (California State University, Dominguez Hills)

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NAME/ADDRESS CHANGE REQUEST (California State University, Dominguez Hills)

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NAME/ADDRESS CHANGE REQUEST
OFFICE OF ADMISSIONS AND RECORDS (WH 290)
FOR OFFICE USE ONLY
Posted By
Date Posted
Last Updated: March 23, 2020
FOR OFFICE USE ONLY
PLACE DATE STAMP HERE
STUDENT ID:
BIRTH DATE:
LAST NAME:
FIRST NAME:
PHONE NUMBER:
EMAIL:
PLEASE CHECK THE APPROPRIATE STATUS:
□ Currently Enrolled Student □ Incoming Student
PLEASE INDICATE THE ITEM THAT YOU ARE REQUESTING TO UPDATE:
□ Update Name □ Update Address
□ Update Telephone □ Update Other ___________________________
NAME CHANGE
APPROPRIATE STATE OR COURT ISSUED DOCUMENTATION IS REQUIRED FOR A NAME CHANGE
FORMER NAME: ______________________ __________________________ __________________
Last First Middle
NEW NAME: ______________________ __________________________ __________________
Last First Middle
ADDRESS CHANGE
PERMANENT ADDRESS: _________________________________________ ___________________
Street 1 Apartment
____________________________ _____________ __________________
City State Zip Code
MAILING ADDRESS: _________________________________________ ___________________
Street 1 Apartment
____________________________ _____________ __________________
City State Zip Code
PARENT ADDRESS: _________________________________________ ___________________
Street 1 Apartment
____________________________ _____________ __________________
City State Zip Code
TELEPHONE CHANGE
HOME PHONE: ______________________ CELL PHONE: ___________________
Phone Phone
___________________________________________________________ _______________________
Student Signature Date
Please email the completed form to admit@csudh.edu. If additional documentation is required, the form and documentation should be submitted
to the Office of Admissions & Records, WH 290
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NAMEADDRESS CHANGE REQUEST (California State University, Dominguez Hills)

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Completed 18 August 2020

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