Change of Permanent Address and/or Home Telephone Number Student Information – please print clearly EMPLID ____________________________________________ D.O.B._______/_______/_____________ This is an application for requesting to change your permanent address and/or home telephone number. Last Name ____________________ First Name ________________________ Middle Initial ________ STUDENT’S SIGNATURE: ___________________________________ DATE: _____/______/______ Phone ( _______ ) ________ --- ________ Email________________________________@LC.CUNY.EDU Please note all documents submitted become the legal property of the college and may not be surrendered back and or copied. If you are moving into NYS, you will not be eligible for in-state tuition for one calendar year. In order to apply for NYS tuition, you must provide documentation and fill out the CUNY residency form. Please go to Shuster Hall room 112 for further details. PRESENT ADDRESS CHANGE TO: ___________________________________ ___________________________________ Street Address Street Address ___________________________________ ___________________________________ ______ _______________ ______ _______________ Apt. # City Apt. # City ___________ ________ - ________ ___________ ________ - ________ State Zip Code State Zip Code OLD TELEPHONE NUMBER NEW TELEPHONE NUMBER ______ - ______ - _ ____ ______ - ______ - _ _____ Are you an Alumni/Alumnus? Would you like to update your information with Alumni Relations? Return this completed form to: Office of the Register, Records & Transcripts Shuster Hall, Room 106 FOR OFFICE USE ONLY Received By: _______________ Date: _____/____/____ Processed By: ______________ Date: _____/____/____ Processed for: (select semester) FALL SPRING SUMMER