Caldwell Community College
and Technical Institute
Permanent Record Change Form
Caldwell Campus
Watauga Campus
2855 Hickory Blvd., Hudson, NC 28638
Post Office Box 3318, Boone, NC 28607
Please submit this form and documentation to Student Services on the Caldwell or Watauga Campus.
My record information is currently listed as:
Last Name
First Name
Middle Name
xxx-xx-
Student ID Number
Date of Birth
Social Security Number
Please make the following changes to my permanent record information.
Change my name to:
Last Name
First Name
Middle Name
Change my address to:
Street Address
City, State, Zip
Change my social security number to:
-
-
Copy of social security card must be attached to process change.
Change my primary phone number to:
Change my secondary phone number to:
Home Cell Work
Home Cell Work
(
)
-
(
)
-
Change my birthdate to:
M
M
D
D
Y
Y
Y
Y
Proof of birth date must be provided.
Authorization
I hereby authorize Caldwell Community College and Technical Institute to change my permanent record information as indicated above.
Signature
Date
For Office Use Only
Updated in Datatel
Staff Initials
Date
cw 4/29/15
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signature
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