Change of Name, Address, or Phone

Each student is required to keep the Registar as well as the Dean of Student Services informed as to his or her address. This form can also be used to update your name and phone numbers.

Name: Name: Title First Middle Last Suffix
Campus Email Address:

e.g., john.doe@student.waynesburg.edu
What information do you wish to change?

What information do you wish to change? Name (additional documentation is required) Home Address Home Phone Mobile Phone
Reason for change:

Reason for change: Other Other
Effective date of change: Effective date of change: / MM / DD YYYY
Requested Name Change: Requested Name Change: Title First Middle Last Suffix
Upload required documentation to support the requested name change.

Attach Files

e.g., court order, marriage license, restoration of former name order, valid driver's license
Are you enrolled in any of the following academic programs which result in licensure?

Are you enrolled in any of the following academic programs which result in licensure? BS in Nursing BSBA Accounting MA Counseling MBA Accounting MBA Finance MBA Human Resources MBA Project Management Education, Teaching Certifications I am not enrolled in any of these programs.
Relocation: Students who relocate to a new state during the course of their program should inquire to learn if the change in residency and/or location will impact licensure requirements and/or financial aid funding. Contact your academic advisor to discuss how this may impact licensure requirements.

Additional information regarding Professional Licensure Disclosure by Program is available on the University website at https://www.waynesburg.edu/professional-licensure-disclosure-program

Relocation: Students who relocate to a new state during the course of their program should inquire to learn if the change in residency and/or location will impact licensure requirements and/or financial aid funding. Contact your academic advisor to discuss how this may impact licensure requirements.

Additional information regarding Professional Licensure Disclosure by Program is available on the University website at https://www.waynesburg.edu/professional-licensure-disclosure-program I have read and understand where to view my program's information.
Current home address/physical location. Current home address/physical location.
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Change permanent home address to: Change permanent home address to:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone: Home Phone: - ### - ### ####
Mobile Phone: Mobile Phone: - ### - ### ####
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.