Fillable Name Change Request SECTION A: Student Information PREVIOUS (Columbia Basin College)

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Name Change Request SECTION A: Student Information PREVIOUS (Columbia Basin College)

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The Name Change Request SECTION A: Student Information PREVIOUS (Columbia Basin College) form is 1 page long and contains:

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Name Change Request
SECTION A: Student Information
STUDENT IDENTIFICATION NUMBER
Student Signature: ________________________________________________ Date: ________________________
Ofce Use Only:
Task: Initials/Date:
Data Input ___________ SM2001 __________/_________________
Make New Label ___________ __________/_________________
Please only use the spaces provided.
Last name (Legal) First name (Legal) M.I.
This example uses all 22 digits available - Lopez-Garcia Lupe G JR
PREVIOUS NAME
Last name (Legal) First name (Legal) M.I.
NEW NAME
Columbia Basin College complies with the spirit and letter of state and federal laws, regulations and executive orders pertaining to civil rights, Title IX, equal opportunity and afrmative action. CBC does not discriminate on the basis of race, color, creed, religion, national or ethnic origin, parental status or
families with children, marital status, sex (gender), sexual orientation, gender identity or expression, age, genetic information, honorably discharged veteran or military status, or the presence of any sensory, mental, or physical disability, or the use of a trained dog guide or service animal (allowed by law)
by a person with a disability, or any other prohibited basis in its educational programs or employment. Questions or complaints may be referred to the Vice President for Human Resources & Legal Affairs and CBC’s Title IX/EEO Coordinator at (509) 542-5548.Individuals with disabilities are encouraged
to participate in all college sponsored events and programs. If you have a disability, and require an accommodation, please contact the CBC Resource Center at (509) 542-4412 or the Washington Relay Service at 711 or 1-800-833-6384. This notice is available in alternative media by request.
SECTION B: Supporting Documentation
In Person
Hawk Central
H Building
Pasco Campus
SECTION C: Where to Submit
Mail
Columbia Basin College
Student Records, MS-H4
2600 N 20th Ave
Pasco, WA 99301
Rev 12’19
Please attach a copy of the following documents:
We are temporarily unable to accept this form 'In Person' while our campuses operate remotely. Please submit the completed
form and documentation via mail (as listed above) or from your CBC email to records@columbiabasin.edu.
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Name Change Request SECTION A: Student Information PREVIOUS (Columbia Basin College)

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Completed 21 July 2020

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