Change of Information Form

Change of Information Form

Information Update*

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Legal Name Change Disclosure

Students may change the name on their academic record for the following reasons: Marriage, Divorce, Legal Name Change, or Correction of an error. Two copies of legal documentation bearing the revised name are required, one of which contains a photograph.

Preferred Name Disclosure

Preferred Name will appear on:

Directory Information (Unless a Family Educational Rights and Privacy Act (FERPA) information block has been requested.
Class roster
Displayed name for College email
Profile on Banner Self-Service
Reports/List generated for faculty and advisors
PCOM Identification Badge

By submitting this completed form, I am declaring a preferred first name. I understand that my preferred first name will appear in accordance with the PCOM Preferred Name Policy. By checking this box, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this form.*

I understand that I must provide two (2) forms of identification with the new name. Once both forms are provided, the Registrar's Office will adjust the name to reflect the new information. At the end of this form, you will be asked to provide the two forms of identification.*

I authorize the office of the Registrar at PCOM to update my information to reflect what is provided below.*

By submitting this completed form, I am updating my gender. I understand that I am signing this Agreement electronically. I agree my electronic signature is the legal equivalent of my manual/handwritten signature on this form.*

Personal Information

Current/Former Student

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First Name*

Middle Name

Last Name*

Name When Attending

Alumni Banner ID/SSN*

Banner ID (900xxxxxx)*

Current Program Year

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Social Security Number

Date of Birth*

Campus*

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Program*

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Phone Number*

Phone

Email Address*

Gender*

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New Address Information

New Street Address*

New City*

New State*

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New ZIP Code*

New Name Information

New First Name*

New Middle Name

New Last Name*

Reminder

Students may change the name on their academic record for the following reasons: Marriage, Divorce, Legal Name Change, or Correction of an Error. Two copies of legal documentation bearing the revised name are required, one of which contains a photograph.

Legal Documentation (Select Two)*

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Attach Documents

File Upload*

Drag and drop files here or

Preferred Name Information

Preferred First Name*

Preferred Middle Name*

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Please check this box if you wish to have your Preferred Name on your eBill for the Bursar.

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