===== PAGE 1 ===== # 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:___ NEW DATA (To be updated in records)

Name:
	Last	First	MI	Maiden

Social Security Number:___ ## FOR OFFICE USE ONLY Date Received/Entered:___ By:___