Fingerlakes Community College Change Of Name Or Social Security Number
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1One Stop Center
3325 Marvin Sands Drive
Canandaigua, NY 14424-8395
(585)785-1000
Change of Name or Social Security Number
This form is to be used to inform the college of a legal name change or Social Security Number correction. Original, unedited documentation (see
examples below) must be presented at the time this form is submitted. We cannot accept this form, or required documentation, by electronic means.
Acceptable Documentation (Change of Name):
Birth Certificate*, Court Order*, Driver’s License, Passport, Social Security Card, Marriage Certificate*.
*Certified copies of these documents can be used if submitting this form via the mail. Please note that certified copies of documentation submitted with a mailed form will
not be returned back to you.
Acceptable Documentation (Change of Social Security Number):
Social Security Card.
Student ID Number:
Name:___________________________________________
Name Change
:
(Please print clearly)
___________________________________________
___________________________________________
Former:
Last
New:
Last
___________________________________________
___________________________________________
Former:
First and Middle
New:
First and Middle
Social Security Number Change:
____________________________________________ ____________________________________________
Former Social Security Number
New Social Security Number
If we have questions about this form, how may we contact you?
Home Phone #: (____) ____-_______ Cell Phone #: (____) ____-_______ E-mail: _______________@______
Reason for Change: _________________________________________________________________________
I certify that the information provided on this form is, to the best of my knowledge and belief, true and correct. I also certify that
the documentation that I am providing is an unedited original or certified copy. I understand that a copy of my documentation
will be retained with this form.
Student Signature: __________________________________________________________ Date: _____________________
Please return form to the One Stop Center; or Geneva, Victor or Wayne County Campus Center.
FOR OFFICE USE ONLY
Type of documentation presented (please take a copy for the record):
Do not update phone #s or email.
NAE
Birth Certificate
Social Security Card
Date Processed: ______________
Court Order
Marriage Certificate
Driver’s License
Staff Initials: ________
Certified Copy ______________
Passport
Type of Documentation
Updated 10/01/15
Nondiscrimination Notice: Finger Lakes Community College does not discriminate based on an individual’s race, color, national origin,
religion, creed, age, disability, sex, gender identity, gender expression, sexual orientation, familial status, pregnancy, predisposing genetic
characteristics, military status, domestic violence victim status, or criminal conviction.
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