Change Of Address Form - Central Connecticut State University
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1Central Connecticut State University
Office of the Registrar
NAME / ADDRESS CHANGE FORM
I.D. NO: ______________________________
DATE: _________________________________________________
LAST NAME: ___________________________
FIRST NAME: _____________________________ M.I.: _________
CHANGE OF ADDRESS
PERMANENT MAILING ADDRESS (Where you want to receive your mail)
STREET: ___________________________________________________________________________________________
CITY, STATE, ZIP: __________________________________________________________________________________
PHONE NO: (
) _____________________________CELL PHONE NO. (
) _______________________________
Optional: LOCAL NON-PERMANENT ADDRESS (for university records only, not used for mailings)
STREET: ___________________________________________________________________________________________
CITY, STATE, ZIP: __________________________________________________________________________________
PHONE NO: (
) _____________________________CELL PHONE NO. (
) _______________________________
CHANGE OF LEGAL NAME
Attach copy of Marriage License, Court Order or Photo Driver License
FORMER NAME: ______________________________________________________________________________________
(Prefix)
(First)
(Middle)
(Last)
NEW NAME: __________________________________________________________________________________________
(Prefix)
(First)
(Middle)
(Last)
ontact the IT HelpDesk by phone at (860) 832-1720,
After the name change has been processed, you may c
or by email at
TechSupport@ccsu.edu to request a change to your CCSU email address. The Card Office,
located in the Student Center, can issue you a new BlueChip card.
Please Note: A student’s preferred (non-legal) first name maybe recorded by the Office of the Registrar for use on
selected internal non-official records. Please visit
to learn more.
STUDENT’S SIGNATURE: __________________________________ DATE: ____________________
Return To:
Office of the Registrar, Davidson Hall, Room 116, 1615 Stanley Street, New Britain, CT 06050
Fax (860) 832-2250 Email regstaff@ccsu.edu
Revised 8/14
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