Va Uni Address, Name, Or Social Security No. Change Form Page 2
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2OFFICE USE ONLY
Completed by: _______________
OFFICE OF THE REGISTRAR
P.O. Box 9217
Date Processed: ______________
Gandy Hall
Virginia State University, Virginia 23806
804-524-5275
ADDRESS, NAME, OR SOCIAL SECURITY NO. CHANGE FORM
Name_________________________________________________ V Number_________________
Last
First
Middle Initial
CHANGE IN PERMANENT ADDRESS
FORMER ADDRESS
NEW ADDRESS
________________________________
_______________________________
Street Address
Street Address
________________________________
_______________________________
City
City
(_____ )________________________
(_______)_______________________
Telephone Number
Telephone Number
CHANGE IN LOCAL ADDRESS
FORMER ADDRESS
NEW ADDRESS
_________________________________
_______________________________
Street Address
Street Address
_________________________________
_______________________________
City
City
(_____ )________________________
(_______)_______________________
Telephone Number
Telephone Number
NAME/SOCIAL SECURITY CHANGE
Previous
:________________________________________________________________
Name
Last
First
Middle
New
:________________________________________________________________
Name
Last
First
Middle
_______________________________________________
New Social Security Number:
Signature___________________________________________ Date_________________________
2
Revised 12/2014
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