Correction of Application Information

Correction of Application Information

Student Information

Student Name*

First Name

Last Name

Term*

Chaffey ID Number

Example: 0123456

Date of Birth *

Email*

If you have been assigned a Chaffey email, all communication will be sent to that account.

Phone Number*

Example: (012) 345-6789

I authorize the office of Admissions and Records to correct the following information submitted on my application for admission:*

Yes

Incorrect Information*

Correct Information*

I understand that additional documentation may be requested to make the correction:*

Yes

I certify under penalty of perjury that the above information is correct. I take full responsibility for any errors and/or incorrect information submitted on my admission application. I understand that failure to report changes in my residency status may result in dismissal or disciplinary action. I also understand that intentionally providing false information may result in legal action.*

Yes

Signature*

[clear]

Use your mouse or finger to draw your signature above

Date*

Admissions & Records

Student has provided required documentation*

Yes; Standard Update Yes; Email Update No

Please select your assigned alpha grouping *

A-Z Backup

Employee Email*

Please state reason below*