Harvard Extension School Student Change Of Address Form
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1For offi ce use only
Division of Continuing Education
Received ________________
Registrar’s Offi ce, 51 Brattle Street, Cambridge, Massachusetts 02138-3722 • Fax: (617) 998-8468
Processed ________________
Student Change of Address Form
You may change your mailing address, e-mail address, telephone number, and emergency contact information online using your Division of Continu-
ing Education ID number (DCE ID, starting with @) and PIN or your Harvard University ID number (HUID) and PIN. Alternatively, or if you
do not know your DCE ID number or PIN, you may submit these changes by mailing or faxing this form to the Division of Continuing Education
Registrar’s Offi ce.
Please print clearly.
STUDENT FULL LEGAL NAME
(exactly as printed on your passport or other government-issued photo identifi cation)
Last/Family/Sur name(s)
First/Given name(s)
Middle name(s)
DCE ID NUMBER
HARVARD ID NUMBER
DATE OF BIRTH
(if known)
(if known)
example:
J A N 0 1
1 9 9 4
or
@
(see if unsure)
Month (MMM)
Day(DD)
Year (YYYY)
Th is is a change to your: ❏ E-mail address
❏
Daytime phone number
❏
Cell phone number
❏
Current mailing address
❏
Permanent address
❏
Emergency contact information
❏ Yes
❏ No
Are you submitting this form because you need to request your DCE ID or PIN?
If yes, DCE ID and PIN retrieval instructions will be e-mailed to the address below.
NEW E-MAIL ADDRESS
(must be student’s personal and unique address)
(check all applicable: ❏ current mailing ❏ permanent)
NEW ADDRESS
Street and number
City
State/Province
Zip/Postal code
Country (if other than US)
NEW DAYTIME PHONE NUMBER
NEW CELL PHONE NUMBER
NEW EMERGENCY NOTIFICATION INFORMATION
First name
Last name
Street and number
City
State/Province
Zip/Postal code
Country (if other than US)
Telephone number (area/country code)
By signing below, I confi rm that the above information is true and correct and I accept full responsibility for submitting it to the Division of
Continuing Education Registrar’s Offi ce.
Student signature _____________________________________________________________________________ Date _________________
Document must be signed with a real signature. Digital signatures are not accepted.
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