West Los Angeles College | Office of Admissions & Records | 9000 Overland Avenue, Culver City, CA 90230 | www.wlac.edu
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
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
*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.
Comments: ________________________________________________________________________________
Date: ________________________________
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