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