Student ID# @
DOB:
MM DD YY
Social Security #
X
X
X
X
X
(Not required if Student ID# provided above.)
► Name Change *
* Must be submitted in person to the Records Office with the following: Official Photo
Identification (drivers license, state of Connecticut ID card or passport) and a Certified Copy
of ONE of the following:
Probate Court Decree ordering a name change
Superior Court Order dissolving a marriage and explicitly ordering restoration of the
name of a party
District Court Order associated with an immigrant becoming a U.S. Citizen
Marriage License.
Former Name
Last, First MI
NEW Name
Last, First MI
Student’s Signature
► Address Change
Name
NEW Address (street)
Last First MI
City/State/Zip Code
Home
Phone Number
( )
Day Time
Phone Number
( )
Email Address
Connecticut Board of Regents for Higher Education
Tunxis Community College Records Office
271 Scott Swamp Road ● Farmington, CT 06032-3187
www.tunxis.edu 860-773-1440
Name/Address Change
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
click to sign
signature
click to edit
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