Proxy Information and Access Update Form
MAIL/E-MAIL FORM AND DOCUMENTATION TO:
COLUMBUS STATE COMMUNITY COLLEGE
OFFICE OF THE REGISTRAR
550 EAST SPRING STREET
C
OLUMBUS, OH 43215
E-
MAIL: resolverppd@cscc.edu
PLEASE PRINT CLEARLY - ALL INFORMATION REQUIRED FOR PROCESSING
PLEASE CHECK THE BOX FOR THE SERVICE YOU ARE REQUESTING:
NAME CORRECTION *:
NAME CURRENTLY ON RECORD: _________________________ ____________________________
FIRST LAST
CORRECT NAME: _________________________ ______________________________
FIRST LAST
*REQUIRED DOCUMENTATION: State Issued Photo ID
E-MAIL CORRECTION:
INCORRECT E-MAIL ADDRESS: ____________________________________________
CORRECT E-MAIL ADDRESS: ____________________________________________
REMOVAL OF PROXY ACCESS:
I decline the right of proxy access for the student named below. Please remove my name from
proxy access.
PROXY NAME: _________________________ ______________________________
FIRST LAST
STUDENT NAME: _________________________ _____ ______________________________
FIRST MI LAST
S
IGNATURE (REQUIRED): _______________________________________ DATE: ___/___/___
**If you would like to have personal information withheld from the directory, you may complete the
Request to Withhold Personal Information From Directory form.
FOR OFFICE OF THE REGISTRAR USE ONLY:
D
ATE RECEIVED: ___/___/___ DATE PROCESSED: ___/___/___
P
ROCESSED BY - SIGNATURE (REQUIRED): _____________________________________________
RLR:prc/Proxy Information and Access Update Form/08-07-2018
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