Office of the University Registrar
P.O. Box 3155
Keeny Hall
Ruston, LA 71272
FAX: 318-257-4041
E-Mail: registrar@latech.edu
For office use only
Updated by:
Date
Revised 9/18/2018
To request change of your address associated with Louisiana Tech University,
complete this form and return to the Registrar’s Office.
The student’s signature and date is required at the bottom of this form.
Please Type or Print Only
PART 1. Student’s Personal Information
Last Name
First Name
Middle Name
Suffix
Campus Wide ID Number (or SS)
PART 2. Student’s Address Change Information
PERMANENT ADDRESS
Street:__________________________________________________________________________________
City: State: Zip: ____________
Phone: __________________________________________________________________________________
LOCAL ADDRESS
Street:__________________________________________________________________________________
City: State: Zip: ___________
Phone: _________________________________________________________________________________
NEXT-OF-KIN INFORMATION
Street:__________________________________________________________________________________
City: State: Zip: ___________
Phone: _________________________________________________________________________________
PART 3. Student’s Signature
My signature below certifies that I am requesting that my address be changed on Louisiana Tech University records and that the
information I have provided on this form is true and accurate to the best of my knowledge.
Signature
ADDRESS CHANGE REQUEST FORM
click to sign
signature
click to edit
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