KENTUCKY STATE UNIVERSITY OFFICE OF THE REGISTRAR PHONE: 502-597-6340 FAX: 502-597-6239

Data Change Form

Personal data submitted at the time of admission will remain unchanged, until filling out this form to indicate changes.

Note: Permanent address changes from Non-Kentucky addresses are prohibited unless approved by the Director of the Registrar, Admissions and Community Programs.

Please complete the following with both prior and updated information.

NOTE: Students must present proof of documentation to the Office of the Registrar.

OLD DATA (Presently in records)

Name:

Last
First
MI
Maiden

Social Security Number:___

Social Security Number

NEW DATA (To be updated in records)

Name:

Last
First
MI
Maiden

Social Security Number:___

Social Security Number

FOR OFFICE USE ONLY

Date Received/Entered:___ By:___

Date Received/Entered

It is the Policy of Kentucky State University not to discriminate against any individual in any of its educational programs, activities, or employment on the basis of race, color, national origin, sex, disability, veteran status, age, religion, or marital status.