I am employed as a work-study or campus-employment student at Lock Haven University.

LHU Student ID #                                   Today's Date (example 01/01/2007)

Name, Last     Name, First      Name, Middle

LOCAL ADDRESS -- This is the address at which you reside while a student at LHUP.  It may change frequently.  It may be a residence hall (please contact the Housing Office, 3rd floor, Sullivan Hall), a local off-campus address, or an address where you are participating in student teaching, an internship, or field experience.

Street

City            State              Zip

Phone -- Area Code Phone Number

County                   Township/Borough

CELL PHONE -- (area code)   (phone number)

PERMANENT ADDRESS -- This address is the one that is least likely to change while you are a student at LHUP.  It is the address where the parent/guardian/spouse would know how to contact you.  To change this to an address other than the one under which you applied for admission to LHUP, indicate in detail the reason you feel this address should be changed.

Street

City            State              Zip

Phone -- Area Code Phone Number

County                   Township/Borough

If you are changing your permanent address to your local address, indicate in the space provided why you are changing your permanent address to your local address.  Reasons stated simply such as "I moved," "I relocated," or "because that's where I live now" will not be accepted.  This should be the address and phone at which a parent or guardian can be reached in the event of an emergency; where student bills, financial aid notifications, or diplomas will be mailed; and where press releases will be distributed about your accomplishments.

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Name Change

If you have changed your name as a result of marriage, court order, etc., please fill in the following information.   Proof of name change (i.e. copy of social security card, court documents, marriage license, etc.) is required.  Please indicate which document you will be providing as proof of name change.  It must be submitted to the Registrar's Office (fax 570-484-2734; mail to or drop off in Russell Hall 127, Lock Haven University, Lock Haven, PA 17745) before the name will be changed.

Copy of social security card                 Copy of court document                  Copy of marriage license

Other, please specify

Previous Name (last)   (first)   (middle)

Current Name (last)   (first)   (middle)
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By checking this box, you are verifying that you are the person whose name appears at the top of this page and that all information is correct to the best of your knowledge.  I so certify .

                                                                                                                                                                                        06/19/2007