Student Affairs—Admissions/Records/Enrollment Services
4501 Amnicola
Hwy., Chattanooga, TN 37406
Phone: 423-697-4401
Return this Application as an attachment to
submit@chattanoogastate.edu
Change of Address/
Phone/Email
Name (please print):
Last First Middle
Date of Birth: Student ID (A Number):
Please Print New Address:
Please check one: Permanent Mailing Both
Street Address:
PO Box (cannot be used as a permanent address):
City: State:
Zip Code: County:
Home Phone: Business Phone:
Apt #
Cell/Mobile Phone:
Personal Email Address:
Student Signature: Date:
Please note: If you are changing your permanent address from another state to Ten-
nessee or a bordering county in Georgia or Alabama, the permanent address cannot
be changed without the required Application for In-State Tuition. This form is located on
the Chattanooga State website under Admissions and Records forms.
Pub. No 11-70-501001-174-10/16-rsf/bap - form 9 – pdf - Chattanooga State Community College does not discriminate against students, employees, or applicants for admission or employment on the basis of race, color, religion, creed,
national origin, sex, sexual orientation, gender identity/expression, disability, age, status as a protected veteran, genetic information, or any other legally protected class with respect to all employment, programs and activities sponsored by
Chattanooga State. The following person has been designated to handle inquiries regarding the non-discrimination policies: Director, Human Resources, 4501 Amnicola Highway, Chattanooga, TN 37406, 423-697-2417.
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