Processed by:
Staff: ____________________________
Date: ____________________________
Email Address:
Home
Cell
Work
_________________________________________________________________
Last Name
_________________________________________________________________
First Name
_________________________________________________________________
Middle Name
Correct TIN/SSN to: __________-_____________-____________
Copy of SSN Card must be attached
Date:
Correct Birthdate to: __________/___________/____________
Copy of government-issued ID or legal documentation must be attached
Student’s Signature
IMPORTANT: To make a change to personal information on your student record, please complete and sign this form. This form must be submitted to the Office of
Admissions and Records in person with photo identification. PLEASE ONLY FILL OUT FIELDS YOU WANT TO CHANGE AND PRINT CLEARLY & LEGIBLY.
NOTE: If you are in the International Student Program (ISP), please submit this form to the International Student Program Office in Bldg. 1600, Rm. 1658.
__________________________________________________________________
Number and Street Apartment #
__________________________________________________________________
City State Zip Code
New Residential Address
OTHER CHANGES
Full Name: ___________________________________________________________________________________________________
Student ID #: _____________________________________________________________ Date: ______________________________
PERSONAL DATA CHANGE FORM
PLEASE PRINT
Last Name First Name Middle Name
NOTE: IF YOU ARE CURRENTLY, OR WERE RECENTLY, A COLLEGE OR DISTRICT EMPLOYEE OF THE CHABOT-LAS POSITAS COMMUNITY
COLLEGE DISTRICT (CLPCCD), YOU MUST VISIT HUMAN RESOURCES TO MAKE CHANGES, NOT ADMISSIONS & RECORDS.
New Mailing Address (if different from Residence)
__________________________________________________________________
Number and Street Apartment #
__________________________________________________________________
City State Zip Code
( ) -
Home
Cell
Work
( ) -
Former Name
New Name
Copy of government-issued ID or legal documentation must be attached
_________________________________________________________________
Last Name
_________________________________________________________________
First Name
_________________________________________________________________
Middle Name
TR 3/25/2019
Notes
Received by:
Staff: ____________________________
Date: ____________________________
Staff Initials: ______________
NAME CHANGE
CONTACT INFORMATION CHANGE
ADDRESS CHANGE
Office of Admissions & Records
3000 Campus Hill Drive, Bldg. 1600
Livermore, California 94551
Tel : (925) 424.1500
Fax : (925) 606.6437
www.laspositascollege.edu/admissions
OFFICE USE ONLY
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