IRSC-44 Rev.8/18
INDIAN RIVER STATE COLLEGE
OFFICE OF STUDENT RECORDS
STUDENT RECORD CHANGE FORM
Check box(es) and complete sections ONLY FOR THE ITEMS TO BE CHANGED.
Return this form to any IRSC campus with the original required documents to be photocopied.
Student I.D. #: Date of Birth:
Current Home Phone: Current Cell Phone:
Name as it currently appears in our system:
Last Name: First: Middle:
CHANGE MY NAME TO: * Driver License, Marriage License, or Court Documents required
New Name: Last: First: Middle:
CORRECT MY DATE OF BIRTH: * Driver License or Birth Certificate required
CHANGE MY ADDRESS TO: *No documentation required
New Address:
City: State: Zip:
New Email Address:
CORRECT MY SOCIAL SECURITY NUMBER TO: *Social Security card required
Student’s Signature Date
SSN CHANGES ONLY
Invalid Student ID#: Invalid Social Security#: Date Processed:
Office Use Only
Received by: Campus:
Send or bring this form along with required original documentation to the Office of Student Records.
*Copies of the full IRSC Notification of Social Security Number Collection and Usage document can be obtained
from Student Services at all IRSC campuses and at the IRSC website at www.irsc.edu.
click to sign
signature
click to edit
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