Student Personal Data Change Request

Student Personal Data Change Request
Submit this form and required documents here or by email to OfficeoftheRegistrar@muskegoncc.edu or by fax to 231-777-0209.
REQUIRED INFORMATION
MCC Student ID#*
Date of Birth*

MonthDayYear
Date
Today’s Date*

MonthDayYear
Date
Name*

First NameMiddle NameLast Name
MCC Email Address*
example@muskegoncc.edu
Current Phone Number*
A VALID, PICTURE FORM OF IDENTIFICATION MUST ACCOMPANY ALL REQUESTS (CHECK ALL THAT APPLY)*

Driver’s LicenseState IDValid Passport (required for F-1 and J-1 international student requests)
REQUESTED CHANGES (Please check all that apply)*

Change address and/or phone number (Section 1)Change residency (Section 2)Correction of existing date of birth (Section 3)Legal change or correction of social security number (Section 4)Legal change or correction of name (Section 5)Gender: MaleGender: FemaleGender: Other (please list)
SECTION 1 - ADDRESS/PHONE NUMBER CHANGE
Address
Apt #, Suite
City
State
Zip
Home Phone
Business Phone
Cell Phone
Emergency Phone
SECTION 2 – RESIDENCY CHANGE
A Michigan Driver’s License or State Issued ID AND one of the following must accompany this request. All documents MUST include the address and be dated at least 6 months prior to the start of the semester. Items must be attached to this form.
Residency Change Documentation Must be Submitted

Voter IdentificationVehicle RegistrationFor Military Personnel, Veterans, and Eligible Dependents Department of Defense 214 or 899 or Certificate of EligibilityProperty LeaseUtility BillVehicle Insurance CertificateProperty Tax ReceiptNotarized verification from a Muskegon County or Michigan resident stating you have resided with him/her for at least six months prior to the start of the semester.
Please Note: Sections 3, 4, and 5 below require a twostep process. (1) Your information will be changed by the Student Welcome Center staff in the database system. (2) The form is then sent to the Office of Information Technology (OIT) so your technology accounts can also be changed. You will be notified by the Office of Information Technology when the changes are complete.
SECTION 3 –BIRTH DATE
A Michigan Driver’s License or State Issued ID MUST accompany this request.
New Birthdate

MonthDayYear
Date
Former Birthdate (currently in system)

MonthDayYear
Date
SECTION 4 – SOCIAL SECURITY NUMBER CHANGE
A Michigan Driver’s License or State Issued ID AND a Signed Social Security Card MUST accompany this request.
New Social Security Number
Former Social Security Number (currently in system)
SECTION 5 – NAME CHANGE
A Michigan Driver’s License or State Issued ID AND one or more of the following MUST accompany this request (check all that apply)

Marriage CertificateDivorce DecreeCourt OrderSigned Social Security Card required for all MCC student
Name

New First NameNew Middle NameNew Last Name
Name

Former First NameFormer Middle NameFormer Last Name
Former Last Name

I am currently enrolled in one or more courses using Black Board.
Note: All MCC student workers must also visit the Payroll Office with a signed social security card to update employment information.

SIGNATURE IS REQUIRED - I authorize Muskegon Community College to update my personal information per this request and to contact me, if necessary, using the information above. I verify all documents and identification presented are current and accurate.
Signature*
Date*

MonthDayYear
Date
Upload the appropriate documents listed above if applicable *

Cancelof
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Student Personal Data Change Request

REQUIRED INFORMATION

SECTION 1 - ADDRESS/PHONE NUMBER CHANGE

SECTION 2 – RESIDENCY CHANGE

SECTION 3 –BIRTH DATE

SECTION 4 – SOCIAL SECURITY NUMBER CHANGE

SECTION 5 – NAME CHANGE