Completion of this form will result in an address change to your permanent record for all Longwood offices.

Note: In some cases, preprinted mailings will be sent to the former address, therefore notifying the U.S. Postal Service is recommended.

Complete this form and return to the address below:

Registration Office
Longwood University
201 High Street
Farmville, VA 23909
Office:    (434) 395-2580
Fax:       (434) 395-2252
                                                                  **   Please Print **

              Student's Name :    ___________________________________________________________
                                                                  Last                                        First                              Middle

              ID Number:   ___________________________________________________________

              New Permanent Address:   ____________________________________________________________
                                                               P.O. Box / Street

                                                              ___________________________________________________________

                                    ___________________________________________________________
                                                                       City                                  State                                 Zip

              Permanent Telephone Number: (         )__________________________________

              New Local (off campus) Address:   ________________________________________________________
                                                               P.O. Box / Street

                                                              ___________________________________________________________

                                    ___________________________________________________________
                                                                       City                                  State                                 Zip

              Local (off campus) Telephone Number: (         )___________________________

Do we have your up-to-date cell phone number?  ___YES   ___NO

If no please list your cell phone number (       )____________________________

Student's Signature:   _________________________                     Date:    ___________________