Student ID Number: ___________________ Date of Birth: _______________________
Name as it currently appears on Palm Beach State records:
__________________________ __________________________ _____________________
Last Name First Name Middle or Maiden
Please complete the appropriate section(s) below.
(Required Documentation:
Photo ID that reflects new
address)
Address: _______________________________________________
Street or PO Box
City: _____________________________ State: _______ Zip: _________
Telephone: ( ___ ) _____________
Area Code
Personal E-mail Address: ________________ @ ________________
(Required Documentation:
Driver’s License, State ID,
Marriage Certificate,
Court Document, or
Passport that reflects new
name)
New Name: _________________________ __________________
Last First Middle or Maiden
Reason for Name Change: ________________________________
Do you want to have your Palm Beach State student E-mail address changed to
reflect your new name? Yes No
Number
Change/Correction
(Required Documentation:
Photo ID
and
Current or Incorrect Social Security Number: _______ / _____ / ______
New or Correct Social Security Number: ______ / _____ / _______
Social
Security Card)
_________________________________________ ___________________________________
Student’s Signature (Required) Date
