Please print clearly in black or blue ink only.
MSJC Student ID#: Term:
Year: _
Student Name:
Last
First
MI
CHANGE or CORRECT NAME:
Current Name:
Last First MI
Previous Name:
Last First MI
You MUST present in person CA driver’s license, marriage certificate, birth certificate or any other legal document to change or correct your
name on record.
CORRECT DATE OF BIRTH:
Incorrect DOB: / / Correct DOB: / /
MM DD YY MM DD YY
You MUST present in person CA driver’s license, birth certificate or any other legal document.
Student Signature:
Date: ____________________
ADD or CORRECT SOCIAL SECURITY NUMBER:
Add SS#:
Incorrect SS#: Correct SS#:
You MUST present in person your official Social Security card to add or correct your Social Security number.
CHANGE or CORRECT GENDER:
PERSONAL EMAIL CHANGE or CORRECTION (for purposes of password reset only):
Incorrect Email: ____________________________
Correct Email: ____________________________
CHANGES COMPLETED (Mark all that apply):
Social Security Number
Name
Date of Birth
San Jacinto Campus
1499 N. State Street
San Jacinto, CA 92583
(951) 487-3215
Fax: (951) 654-6738
Menifee Valley Campus
28237 La Piedra Rd.
Menifee, CA 92584
(951) 639-5215
Fax: (951) 672-6548
San Gorgonio Pass Campus
3144 W. Westward Ave.
Banning, CA 92220
(951) 922-1327
Fax: (951) 922-1408
Temecula Higher Education Center
43200 Business Park Drive
Temecula, CA 92590
(951) 506-6752
click to sign
signature
click to edit
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click to sign
signature
click to edit
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