Social Security Number
ADDRESS/NAME CHANGE --

Name in DMACC Records

Last

                           First

Middle Initial

Check one:   Student       Employee    Both

Name Change                   
               Effective Date:

Old name:

 New Name:

Last

                           First

Middle Initial

 *In order to change a name previously established with DMACC, legal
Last

                                     First                            

Middle Initial

evidence verifying the name change may be required.

Address Change                               Effective Date:

  New Address:  Permanent         Mailing        Temporary (from:                                          to:                            )

Street / Box No.

City / State / Zip / Country

Telephone Number Change              Effective Date:

Home Telephone Number Business Telephone Number
-- --

Signature                                                                                                                  Date

Please return all copies to issuing office                                            Distribution: Student Records/Human Resources