Office of the Registrar
PERSONAL DATA CHANGE REQUEST FORM
(Address, Telephone Number, Name, Date of Birth, Social Security Number)
Please
check all that apply.
I am a: Current Student Prior Student Alumni
Important: You must complete all information requested. Submit this form along with supporting documentation to
the address below.
R
equired Information: This information must be noted as it currently appears on the records of the College.
CUNY FIRST ID # Social Security No. (Last 4 Digits)
Last Name _____________________________________________
________ First Name __________________________________________ Middle Initial ________
Day Phone # ___________________________________________________ Email _____________________________________________________________________
Signature (Required): ____________________________________________________________________________________ Date _____________________________
Address and Telephone Number Change
Check preferred telephone number.
Home Phone # ________________________________________ Mobile (Cell) _______________________________________________
Enter new Social Security number:
A
ddress for Submission:
Office of the Registrar
Queensborough Community College
222-05 56th Avenue, A-104 Bayside,
NY 11364
FAX: 718-281-5041 PHONE: 718-631-6212
EMAIL: Registrar@qcc.cuny.edu
2/2019
Work
Phone # ___________________________________________________
Address ____________________________________________________________________________________________________________________________________
City ______________________________________________________ State _________ Zip ______________________ County ______________________________
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 documenta-tion. If
this change of address is from NY State to another state your tuition charges 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 College International
Student Coordinator located on campus concerning any changes.
Name and Date of Birth Corrections
CUNY requires legal documentation for any updates to Name or Date of Birth.
Please attach two (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 (e.g. driver's license). Employees must notify Social
Security of any legal name change.
Incorrect DOB: ___________________________________________________ Correct DOB:l____________________________________________________________
Complete New Name:
Last Name _____________________________________________________ First Name __________________________________________ Middle Initial ________
Complete Former Name (As it currently appears in records of the College):
Last Name _____________________________________________________ First Name __________________________________________ Middle Initial ________
Social Security Number change
Please attach a copy of your Social Security Card and a photo ID.
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