Name/Address Update Form Please print clearly and provide all of the information requested.
Student ID #_____________________________________________________________Date of Birth_______________________________________________________ Name__________________________________________________________________________________________________________________________________________ Last
First
Middle Initial
Name Change
Name changes require official documentation showing change. Acceptable documents include marriage licenses, court ordered name change documents, and social security cards. These documents must be attached or a name change cannot be processed by our office.
New Last Name_______________________________________________________________________________________________________________________________ New First Name ______________________________________________________New Middle Name/Initial___________________________________________
Address Change OLD ADDRESS: Street_____________________________________________________________________________________________Apartment/Unit #________________________ City____________________________________________________________________ State_________________________________Zip______________________________ Country (if other than USA)__________________________________________
NEW ADDRESS (check all that apply):
Permanent Address
Local Address
Mailing Address
Billing Address
Street_____________________________________________________________________________________________Apartment/Unit#_________________________ City____________________________________________________________________ State_________________________________Zip______________________________ Country (if other than USA)__________________________________________ Home Phone_____________________________________________________ Cell Phone_________________________________________________________________
Emergency Contact Information Name_______________________________________________________________Phone____________________________________________________________________ Street_____________________________________________________________________________________________Apartment/Unit#_________________________ City____________________________________________________________________ State_________________________________Zip______________________________ Country (if other than USA)__________________________________________ Required Signatures: Student Signature________________________________________________________________________________________________ Date_______________________ Registrar Use Only:
Processed by__________________________________________________________________________Date______________________