Pitzer College Address Change Form
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1Pitzer College
Office of the Registrar
ADDRESS CHANGE FORM
STUDENT NAME ________________________________________ ID NUMBER _______________
New Address:
Street
___________________________________________________________
City
___________________________________________________________
State
_____________________________ Zip __________________________
Telephone
(________)__________________________________________________
Check one:
Cell
Home
Work
Emergency Contact:
___________________________________________________________
Name
Telephone
(________)__________________________________________________
Check one:
Cell
Home
Work
Check appropriate NEW address categories (check all that apply):
Permanent
Local
Billing
Parent’s address or
Mother’s address
Father’s address
Old address to delete:
Street
___________________________________________________________
City
___________________________________________________________
State
_____________________________ Zip __________________________
Telephone
(________)__________________________________________________
Check one:
Cell
Home
Work
Emergency Contact:
___________________________________________________________
Name
Telephone
(________)__________________________________________________
Check one:
Cell
Home
Work
Check appropriate NEW address categories (check all that apply):
Permanent
Local
Billing
Parent’s address or
Mother’s address
Father’s address
IS THIS INFORMATION RESTRICTED?
YES
NO
Student Signature: __________________________________________ Date ________________________
Office use:
Date Processed _________________________ Initials ____________
s:/forms/addresschange.doc
Updated 08/07
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Parent category: Legal