Brookhaven College Student-Information Change Request
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1Brookhaven College Student-Information Change Request
Name: __________________________________________
_________________________
Last
(Please Print)
First
M
Student Identification Number
Section 1
Address / Phone Change
Note:
*
If your previous address was outside of Dallas County and your new address is in Dallas County: you
MUST provide two proofs of Dallas County residency to be attached to this form before residency status can be changed.
Previous Address / Phone
New Address / Phone
_________________________________
_________________________________
Street
Street
_________________________________
_________________________________
City
State
Zip
City
State
Zip
_________________________________
_________________________________
Area Code - Phone Number
Area Code - Phone Number
_________________________________
_________________________________
E-mail Address
E-mail Address
Section 2
Name Change
* Note:
Legal documentation must be presented and attached with this request. Examples: court order,
marriage license, divorce decree or driver license with new name.
Former Name
New Name
_________________________________
_________________________________
Last
(Please Print)
First
M
Last
(Please Print)
First
M
Section 3
Social Security Number Change
* Note:
The new social security card must be presented and a copy attached to this form.
_________________________________
Incorrect Social Security Number
_________________________________
Correct Social Security Number
Student Signature: ___________________________________________ Date: ____________
By my signature I affirm that the changes above are true and correct.
I T AL L B EG IN S H ER E.
Admissions and Registrar’s Office
3939 Valley View Lane | Farmers Branch, Dallas, TX 75244-4997
| bhcAdmissions@dcccd.edu | 972-860-4883
Educational and employment opportunities are offered by Brookhaven College without regard to race, color,
age, national origin, religion, sex, disability or sexual orientation. M&PI Office, April 2007, #704005R.
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