SCHENECTADY
COUNTY
COMMUNITY
COLLEGE
PERSONAL INFORMATION
CHANGE REQUEST
To make a change to personal information on your student record, please complete and sign this form. This form
must be submitted to the Registrar’s Office in-person with picture ID.
Name
Last First Middle
ID Number Date of Birth
Please mark an “x” in the box(es) next to the type(s) of information you would like to change (check all that apply):
□
Address/Telephone
Change – Select the type of address below to change or add to your record.
□
A permanent address is one at which you have a primary and permanent residence. A local address can be created by
those who have a permanent residence out of the area to which they plan to return.
Be sure to include your current phone number even if it has not changed.
□ Permanent Address:
Apt
□ Local Address:
Apt
Phone Number: (
Cell Phone Number: (_
Effective Date:
)_
_)
-
-
Phone Number: (
Cell Phone Number: (_
Effective Date:
)
_)
-
-
□ Name Change/Correction – Form must be accompanied by social security card. Your name on file with
the College must match your name as filed with the Social Security Administration. Those not eligible for a
social security number must provide other legal documentation (i.e. ITIN letter or court documentation).
Please provide new name
Last First Middle
Current name on record
Last First Middle
□ Social Security Number Entry/Correction – Request must be accompanied by social security card.
Office use only: Incorrect social security number on record
□ Date of Birth Entry/Correction – Form must be accompanied by driver’s license or birth certificate.
Office use only: Incorrect date of birth on record
Signature ________________________________________________________________________________ Date ______________________________
For Office Use Only: Date Processed________________ Processed By_____________________
Form: REG-PIC-1
click to sign
signature
click to edit
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