Original Registrar’s Office Yellow copy Student
RO-004/Revised: TL-04/2020
Please check all that apply: I am a Current Student Prior Student Alumni
IMPORTANT: Original official documentation must accompany this request. Submit this form to the Registrar’s
Office, room C-107.
Original Registrar’s Office Yellow copy Student
Office use only
Office of the Registrar - Division of Student Affairs
Personal Data Change Request
(Name, Date of Birth, Address, Telephone and Social Security Number Changes)
Last Name
First Name
NAME CHANGE/CORRECTION: CUNY requires LEGAL documentation for any change in name. Attach
2 types of appropriate documentation. One type of documentation must be either a marriage certificate, passport,
birth certificate, social security card, divorce decree or a court order, the second must be a photo ID.
Complete New Last Name
First Name
Complete Former Last Name First Name
Middle Name/Initial
Middle Name/Initial
DATE OF BIRTH CORRECTION: Attach a copy of your Birth Certificate and Social Security Card.
Old DOB:
New DOB:
Old Social Security #:
New Social Security #:
ADDRESS AND/OR TE EPHONE NUMBER CHANGE: Please check all that apply*
Home Mailing Billing Permanent Telephone Number
House Number/Street
Apt №
City State
Zip Code
Phone №
*Further instructions
If this change of address is from another state to New York State a student must submit official proof of their change of
residence. To qualify for in-state tuition a student must also submit a completed residency request form with the appropriate
documentation. If this change of address is from NY State to another state your tuition charge will be updated to reflect your
out-of-state status. If you are a foreign student, on a visa, your permanent residence must remain your home country. The
student must also notify the International Student Services Office (room B-117) concerning any changes.
Student’s Signature:
Signature from Pick-up:
Processed by: Date: