Rev Aug 2016
RECORDS CHANGE FORM
21250 Stevens Creek Blvd.
Cupertino, CA 95014
FAX 408.864.8329
(X)
Check all that apply
Name Change
Social Security Number Change
Required Information: Provide as it currently appears on your De Anza record
CWID/SID:
Name:
Last First
MI
CWID/SID:
Name:
Last First
MI
Follow ONE of these steps to submit your change request for processing:
1. Bring this form along with your Social Security Card and current photo Identification to
the Admissions and Records Office OR
2. Scan and e-mail all documents to webregda@deanza.edu
Phone: _______________________ Email Address: __________________________
Student Signature _________________________ Date __________________
FOR OFFICIAL USE ONLY – ADMISSIONS & RECORDS STAFF
Completed by: Date: Notified (In-person, Email, Phone):
Contact Information: Please provide your current contact information and signature
Change Request: Provide ONLY the information that you want changed
click to sign
signature
click to edit
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