West Los Angeles College | Office of Admissions & Records | 9000 Overland Avenue, Culver City, CA 90230 | www.wlac.edu
STUDENT INFORMATION CHANGE FORM
Clearly fill in the below information as it PRESENTLY EXISTS on your record EVEN IF IT IS INCORRECT
Last Name
_____________________________________________________
First Name
________________________________
Middle Initial
__________
Student ID Number
_____________________________________________________
Birthdate
________________________________
Clearly fill in ONLY that information you want CHANGED
[ ] Primary Name (Legal) [ ] Preferred Name [ ] Both
Last Name
_____________________________________________________
First Name
________________________________
Middle Initial
__________
[ ] National ID
_____________/______________/_____________
Social Security Number
[ ] New Email
____________________________________________
[ ] Telephone Number ( )
[ ] Correct Birthdate
____________________________
[ ] Home Address [ ] Mailing Address [ ] Billing Address
_________________________________________________________________________________________________
Number Street Apt No. City State Zip
[ ] Residency Status
__________________________________________________
[ ] Educational Status
_________________________________________
Associates or Bachelors ONLY
[ ] Duplicate Student Identification Numbers:
ID# ___________________________________ ID# ___________________________________
I declare that the information supplied by me on this form is true and complete to the best of my knowledge. I
authorize this change of information for all records pertaining to me held or maintained by the College, including
educational, financial and employment records. I understand that any falsification of information or intentional
misuse of this form may be grounds for disciplinary action, up to and including dismissal from the College.
_____________________________________________________________
Student Signature
___________________________________
Date
*Information updates should ordinarily be submitted in person to the Office of Admissions and Records on the second floor of the Student
Services Building. However, if you are a distance education student or otherwise cannot make it to the office in person, you may mail the
form, along with a copy of a government-issued ID, to our office. Please use the address found at the bottom of this form.
ADMISSIONS OFFICE USE ONLY:
Comments: ________________________________________________________________________________
___________________________________________________________________________________________
Date: ________________________________
2/2020
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