Student-Change-Of-Address-Form.Pdf

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Harvard Extension School • Harvard Summer School Registrar’s Offi ce • 51 Brattle Street, Cambridge, Massachusetts 02138-3722 For offi ce use only (617) 998-8469 • [email protected] Received ________________ Processed ________________ Student Change of Address Form You may change your mailing address, e-mail address, telephone number, and emergency contact information online using your Division of Continu- ing Education (DCE) or your Harvard University (HU) login credentials. Alternatively, or if you do not know your login credentials, you may submit this form to the Registrar’s Offi ce at the address or e-mail above. Please print clearly. STUDENT FULL LEGAL NAME (exactly as printed on your passport or other government-issued photo identifi cation) Last/Family/Sur name(s) First/Given name(s) Middle name(s) DCE ID NUMBER (if known) HARVARD ID NUMBER (if known) DATE OF BIRTH example: JAN 01 1994 @ or (see www.extension.harvard.edu/login if unsure) Month (MMM) Day(DD) Year (YYYY) Th is is a change to your: ❏ E-mail address ❏ Daytime phone number ❏ Cell phone number ❏ Current mailing address ❏ Permanent address ❏ Emergency contact information Are you submitting this form because you need to request your DCE ID or PIN? ❏ Yes ❏ No If yes, DCE ID and PIN retrieval instructions will be e-mailed to the address below. NEW E-MAIL ADDRESS (must be student’s personal and unique address) NEW ADDRESS (check all applicable: ❏ current mailing ❏ permanent) Street and number City State/Province Zip/Postal code Country (if other than US) NEW DAYTIME PHONE NUMBER NEW CELL PHONE NUMBER NEW EMERGENCY NOTIFICATION INFORMATION First name Last name Street and number City State/Province Zip/Postal code Country (if other than US) Telephone number (area/country code) By signing below, I confi rm that the above information is true and correct and I accept full responsibility for submitting it to the Division of Continuing Education Registrar’s Offi ce. Student signature _____________________________________________________________________________ Date _________________ Document must be signed with a real signature. Digital signatures are not accepted. ext/ss_add.pdf.

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