Transcription of Change of Personal Information Request
1 Updated 9/16/2016 Change of Personal Information Request RETURN THIS form IN PERSON, WITH PHOTO ID TO: Welcome and One Stop Center B114 19351 West Washington Street Grayslake Illinois 60030-1198 Phone: (847) 543-2061 Fax: (847) 543-3061 Forms may be returned via fax or mail, but a copy of the student s photo ID with signature must be included for identity verification. If there is any question about identity, the student may be asked to provide identification in person. Previous Information Name as currently recorded:_____ CLC ID#_____ Are you employed by CLC? Yes No New or Corrected Information - List ONLY the items that are new or changed Personal Information : Personal Information changes must be accompanied by a copy of one of the following: Illinois driver s license, Illinois identification card, social security card, or other approved documents.
2 Name: Last:_____ First:_____ Middle:_____ Birthdate (MM - DD - YYYY):_____--_____-- _____ Social Security Number (### - ## - ####): _____--_____--_____ myLogin Username (for myCLC, student email, and Blackboard):_____ I understand that all email messages and contact Information associated with my former username and email account will be deleted when my username is changed. Address and Contact Information : Changes that affect tuition residency status must be accompanied by a copy of one of the following: Illinois driver s license, Illinois identification card, Illinois voter ID card. Other documents may be accepted - see college catalog for details. Permanent Legal Address: I occupy a dwelling and have resided here for 30 or more consecutive days.
3 Address:_____ City:_____ State:_____ Postal:_____ Mailing Address: I have a 2nd address for the purpose of receiving mail. Address:_____ City:_____ State:_____ Postal:_____ Phone Number: Students can update their phone numbers anytime in myStudentCenter. Home:(_____)_____ Work:(_____)_____ Cell:(_____)_____ Home Email:_____ Citizenship/Residency Status:_____ Other Change :_____ CERTIFICATION: I hereby affirm that the Information given above is legally true and correct. I understand that giving false Information may make me ineligible for admission to the college or subject to dismissal. _____ (Student Signature) _____ (Date)
