subject_line
Request for Change in Records
Campus
*
Stockton
Modesto
Current Name:
*
Student ID Number:
*
Last 4 SSN:
*
Please make the following changes in my records. (Mark the appropriate box.)
Change in:
*
Name
Address
Telephone
Email
Name Change:
(To process name change, formal documentation must be submitted, i.e. marriage or driver’s license.)
New Name
*
Previous Name
*
Address Change:
New Address
*
Previous Address
*
Telephone Change:
New Phone Number
*
New Phone Type
*
Cell
Home
Work
Previous Phone Number
*
Email Change:
New Email Address
*
Previous Email Address
*
Student Signature:
*
clear
Today's date
*
+
Request for Change in Records
/
Humphreys University
/
Registrar's
Department