Registration and Records
800 Main Street, Pewaukee, WI 53072
262.691.5578 (Phone)
262.691.5123 (Fax)
WebReg@wctc.edu
Student Record Change
4641/13
Date submitted ____________________________________________
Please complete this form and mail or fax to Registration and Records
Name ______________________________________________________________________________________________________
Student ID/Social Security # ____________________________________________________________________________________
Change from: To:
Name
(documentation required) ____________________________________________ ____________________________________________
Social Security #
(documentation required) ____________________________________________ ____________________________________________
Gender
(documentation required) ____________________________________________ ____________________________________________
Home address
____________________________________________ ____________________________________________
City, State, Zip
____________________________________________ ____________________________________________
Home phone
____________________________________________ ____________________________________________
Work phone
____________________________________________ ____________________________________________
Other
____________________________________________ ____________________________________________
Please check documentation, if required above. Attach a photocopy of document.
______ WI Drivers License ______ Social Security Card ______ Birth Certificate ______ Other
Signature of Requestor/Date ________________________________________________________________________________
For office use only
Date entered ______________________ Initials __________________