MJC Enrollment Services Phone (209)575-6853
EAST 435 College Avenue, Student Services Bldg. 1st Floor WEST 2201 Blue Gum Ave, Yosemite Hall 1st Floor
It is important that the college has accurate information for every student. It is the students’ responsibility
to report any changes in their personal information. Name changes will cause current PiratesNet email to
become invalid at 10 pm on the business day the change is made.
Today’s Date:
Student Information
Last Name: First Name: Middle Initial:
Student ID: w Birthdate: Phone:
CHECK THE APPROPRIATE BOX AND COMPLETE THE INFORMATION TO BE CHANGED:
Legal Name Change from: to:
Birthdate from: to:
SSN from: to:
Email from: to:
Other Explain:
Please Note: Legal documentation and photo ID are required in order to complete the change request.
Student Signature: Date:
04/2019_SJB
Personal Information Update
Submit completed form in-person to Enrollment Services
on East or West Campus with photo identication.
OFFICE USE ONLY
Identication Presented: Driver License Passport Birth Certicate SS Card Student ID
Other
Sta Initials: Date: Application Error
Comments:
