11-21-2017
www.southeasterntech.edu
__________________________________________________________________________________________
SWAINSBORO 346 Kite Road • Swainsboro, Georgia 30401 • Phone (478) 289-2200 • Fax: (478) 289-2263
VIDALIA 3001 East First Street • Vidalia, Georgia 30474 • Phone (912) 538-3100 • Fax (912) 538-3156
Southeastern Technical College is an Equal Opportunity Institution
NAME AND ADDRESS CHANGE FORM
SS#:____________________________ Currently Enrolled: Yes____ No____
Current Name: ____________________________________________________________
Please print your New Name as it appears on Social Security Card - Verification Required
New Name: ______________________________________________________________
You MUST provide a copy of your Social Security Card AND one of the following legal documents verifying
your name change:
Marriage License/Certificate
Divorce Decree
Court Order
Adoption Papers
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New Address: __________________________________________________________
City: State: Zip: ______________
County: _____________________________________________
Telephone Number: ___________________________________
Email Address: _______________________________________
Student Signature: _____________________________________ Date:_____________
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