Office of the Registrar

641-3165

ADDRESS CHANGE FORM

STUDENT ID#:

EFFECTIVE DATE:

NAME:

CAMPUS BOX:

CAMPUS EXT.:

E-MAIL:

OLD ADDRESS:

STREET OR RD
BOX OR APT #

CITY
STATE
ZIP

NEW ADDRESS:

STREET OR RD
BOX OR APT#

CITY
STATE
ZIP

TELEPHONE NUMBER:
(OLD) (NEW)

CHECK ALL THAT APPLY

This is:
Permanent Change
Temporary Change
from
to
Student Address
Parent/Guardian/Spouse Address
Billing Address