SIU School of Medicine

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Office of Student Affairs

 

Official Student Address/Phone Change Request

If you are making a name change, you need to use a Name Change form.

Class of:
First Name:
Last Name:
Email:

Change Local/Billing Address and/or Phone Number to:
Street City

State

 Zip Area Code/Phone #

Change Permanent Address and/or Phone Number to:
Street City

State

 Zip Area Code/Phone #

If you would like a printout of this form click on the print button before clicking on the submit button.