Office of the Registrar
Jefferson 100
65-30 Kissena Blvd.
Flushing, NY 11367
718-997-4400
qc.registrar@qc.cuny.edu
Change of Name, Address,
or Student Number
Instructions: Complete the top part of this form to include the date, your full name, and contact information.
Complete the applicable sections below and then sign and date the bottom of the form. Any field marked with an
asterisk (*) must be completed in its respective area. Name and Number Changes Only: original documentation
must be presented when this form is submitted. Photocopies of original documents will not be accepted.
This completed form and original documentation must be submitted to the One Stop Service Center (DH 128).
Incomplete forms will not be processed.
*Student ID _____________________
*Full Name _______________________________________________
*Phone ________________________
*E-Mail ________________________________
Change of Name
Note: “Other” documents are accepted on a case-by-case basis depending on the request. Please be prepared to supply a Birth/Marriage Certificate, Court
Order, or Divorce Decree upon request.
*New Name
First
Last
Middle
First
Last
Middle
*Former Name
*Documentation:
Birth or Marriage Certificate
Court Order
Divorce Decree
Other ___________
Change of Address
Note: This form will only update a student’s permanent address. Students must update their Home, Billing, and Mailing address on their own in CUNYfirst.
*Number and Street
Apartment
*City and State
*Zip Code
Change of Student Number (SSN or TIN Update Only)
*New Student #
Old Student #
*Date of Birth
*Documentation:
Social Security Card
I am adding a TIN to my record.
If this area is not signed and dated, your request will not be processed.
*Student Signature
*Date
04/07/2015 KH