Student ID#: ___________________
Last Name: ________________________________ First Name: _______________________ Middle Initial: __________
Name Change - Complete this section if you are requesting a name change in your student records.
If you are requesting a change of legal name, you must provide:
1. A completed Change of Biographical Data form.
2. Legal documentation showing both the previous and the new name. Acceptable documents include: birth, marriage, or
divorce certificate; divorce decree; immigration papers such as certificate of naturalization or permanent resident card;
or other certified court documents.
3. Photo identification.
Note: Changing your name will also change your CCCC email address and Moodle access. For more information, contact the Help
Desk at helpdesk@capecod.edu or 774.330.4004 and Moodle Student Help at moodlestudenthelp@capecod.edu
or
508.375.4040.
Student’s Previous Legal Name:
Last Name: _______________________________________ First Name: _________________________ Middle:______________
Student’s New Legal Name:
Last Name: _______________________________________ First Name: _________________________ Middle:______________
Preferred First Name*: ___________________________________
* Fill this in only if your new legal name is not the same as the name you prefer to be called.
Address and/or Phone Change - Complete this section if you are changing your mailing address and/or phone number.
New Mailing Address: _____________________________________________________________________________________
City: _________________________________________________ State:_____________________ Zip Code:________________
New Mobile Number: _____________________________________ New Email: ______________________________________
Social Security Number Change - Complete this section if you are changing your social security number. In addition to this form,
documentation from the Social Security Administration and photo identification are required.
Social Security Number: ____ ____ ____ - ____ ____ - ____ ____ ____ ____
Gender Change - Complete this section if you are requesting a change in records in regards to your gender. In addition to this
form, provide original or notarized copies of court documentation of legal gender change and photo identification.
New Gender: _________________
The College reserves the right to modify, change, alter or rescind at any time and at its discretion its Changing
Biographical Data policy. No changes will be made without student signature and appropriate documentation.
Student Signature:____________________________________________________ Date_________________________
Office of the Registrar – CHANGE OF BIOGRAPHICAL DATA FORM
2240 Iyannough Road │ West Barnstable, MA 02668
774.330.4711 │ Fax: 508.375.4084 │ registration@capecod.edu │ www.capecod.edu
