Student Record Change Form
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1Florida State College at Jacksonville
Student Record Change Form
Student Name: ______________________________________I.D. Number (SSN): __________________________
Please print clearly to update the sections that apply. Student signature in Section IV is required.
Section I:
Name Change
(Please attach proof: Copy of Marriage/Divorce/Court Order/Driver’s License)
Change Name from: _____________________________________ to: _____________________________________
C
Court Order
D
Divorce
E
Student Preference
I
Misspelled
M
Marriage
O
Other (Please Explain) _______________________________________________
P
Program Error
R
Request with Documentation
S
Sex Reassignment
Section II:
Student I.D. Number Change (SSN)
(Please attach copy of Social Security Card)
Change number:
From: ________-________-___________ To: ________-________-___________
C
Court Order
D
From Default # to SSN
I
Data input error
M
Military Partial Student ID
O
Other (Please Explain) ________________________________________________
R
From SSN TO Default #
S
Social Security Admin Reassigned
Section III:
Change Mailing Address / Contact Phone Number
Old Address: ____________________________________________________________________________________
Street – Number and Name
Apt #
City
State
Zip
New Address: ___________________________________________________________________________________
Street – Number and Name
Apt #
City
State
Zip
Home Phone: __(______)__________________________ Work Phone: __(______)___________________________
Section IV:
Student Signature (required)
Signature: ___________________________________________ Date: _____________________________________
Processed By: ____________________________________
______________________
___________________
Campus Representative
Campus ID
Date Processed
DSRO updated 8/09
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Parent category: Legal