Office of the Registrar

ADDRESS/EMAIL/TELEPHONE CHANGE FORM
Mail to: UNC at Pembroke Office of the Registrar P.O. Box 1510 Pembroke, NC 28372	or	Fax: 910-521-6328


Directions: Please print, complete and return to the Office of the Registrar. * Student workers and current employees return this form to Human Resources. *


UNCP ID	Date	Date of Birth


First Name	Middle Name	Last Name

ADDRESS TYPES: (Please use the address type and indicate this below.)
DM (Diploma Mailing Address)		LO (Local Mailing Address)
EC (Emergency Contact)		MA (Permanent Mailing Address)

Mailing Type:


^{PO Box/RFD/Street}	^City	^State	^{Zip Code}


EMAIL TYPES: (Please check the email type you are changing.)
	___UNCP (UNCP Email Address)	___PERS (Personal Email Address)
	___PARN (Parent’s Email Address)	___EMPL (Employment Email Address)

New Email Address:

TELEPHONE TYPES: (Please use the telephone type and indicate this below.)
	CA (Campus Address Telephone)	DM (Diploma Mailing Address Telephone)	EC (Emergency Contact Address Telephone)
	LO (Local Address Telephone)	MA (Mailing Address Telephone)

Telephone Type		Telephone Number

Statement of Responsibility:

I assume responsibility for the consequences or problems that may occur as a result of this change of my name. There is no intent on my part to defraud the University of North Carolina at Pembroke.

Signature

Date

Check all that apply
	Alumni	Faculty	Friend	Staff	Student

Return this form, with proper documentation, to the appropriate office below.
	Alumni/Friends: Office of Advancement, 442 Lumbee Hall, PO Box 1510 , Pembroke , NC 28372-1510
	Faculty and Staff: Human Resources, 347 Lumbee Hall
	Students: Office of the Registrar, 133 Lumbee Hall
	Prospective Graduate Students: Graduate Studies, 253 Lumbee Hall
	Prospective Students: Undergraduate – Admissions, 224 Lumbee Hall


FOR OFFICE USE ONLY

Receiving Department

Date

Changed by Name

Date

Required Documents: (Choose one of the following)

Students

Driver’s License	Social Security Card
Marriage License	Other (Divorce Decree or other Court Documents supporting a name change)

Employees

Social Security Card (Required)

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ADDRESS/EMAIL/TELEPHONE CHANGE FORM