Anoka Technical College is an affirmative action, equal opportunity employer and educator, and a member of the Minnesota State Colleges and Universities
system. This document is available in alternative formats to individuals with disabilities by calling (763) 576-4700, TTY: 7-1-1 or (800) 627-3529.
1355 West Highway 10
Anoka, MN 55303
www.anokatech.edu
Student Name, Address or E-mail Change Form
01/10
Name_____________________________________________________________ SSN# or Student ID____________________
Name last registered under________________________________________________________________
Program_____________________________________________ New Phone# ________________________________________
New Address______________________________________________________________________________________________
__________________________________________________________________________________________________________
Old Address______________________________________________________________________________________________
__________________________________________________________________________________________________________
New E-mail Address_______________________________________________________________________________________
Effective Date of Change________________________________
Student Signature______________________________________________ Date____________________________________
Student must provide picture id and legal documentation supporting name change in person at the
records/registration office.
LAST FIRST MI
STREET
Please Check: Name Change Permanent Address Change Email Address Change
LAST FIRST MI
CITY STATE ZIP
STREET
CITY STATE ZIP
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