LONG ISLAND UNIVERSITY- BROOKLYN CAMPUS
OFFICE OF THE REGISTRAR
REQUEST FOR CHANGE OF STUDENT INFORMATION
NAME ON SCHOOL RECORDS:
____________________________________________________________________________
LAST 
FIRSTMIDDLE
ID NUMBER______________
MAJOR:___________
FILL IN ONLY THOSE ITEMS TO BE CHANGED:
NEW ADDRESS___________________________________________________________________
NUMBERSTREETAPT
________________________________________________
CITYSTATEZIP
CODE
NEW NAME:_____________________________________________________________________
LAST FIRSTMIDDLE
SIGNATURE___________________________________________________________________
NEW
TELEPHONE
NUMBER: (______ ) ______________________________
CORRECTED
DATE OF BIRTH______/_______/______
MONTH
DAY YEAR
NEW ID
NUMBER________________________________________
DATE __________/__________/_______________
FOR OFFICE USE ONLY
AUTHORITY FOR CHANGEBIRTH
CIRTIFICATE
MARRIAGE CERTIFICATE
DIVORCE DECREE
COURT ORDER
COMPUTER
ENTRY ERROR
RESUMPTION OF MAIDEN
NAME
SOCIAL SECURITY CARD.
FOR CHANGE OF ID ONLY
OTHER
ORIGINAL SEEN BY ___________ DATE
_______/________/_______ RC_________DATE______/______/______
COMP_______DATE____/____/____FILE_______DATE______/______/______