FULL NAME:___________________________________________________________________
(First, Middle, Last)
YSU ID or SSN:________________________________________
To request that your academic record be changed:
- Complete only the items you are requesting to change
- Provide a valid State or Federal issued photo ID (i.e. driver's license or passport)
- Attach legal document(s) supporting the change(s) when necessary
Completed form can be faxed (330-941-1408), mailed, or submitted in person to the Penguin Service Center, second floor Meshel Hall.
I WOULD LIKE TO:
___ Change my ADDRESS and/or PHONE NUMBER to now appear on record as:
PERMANENT ADDRESS
Street Address:____________________________________________________________________________________
City: _____________________________________ State: ___________________________ Zip Code:_______________
Permanent Phone Number______________________________________
MAILING ADDRESS: (if different than permanent address)
Street Address:____________________________________________________________________________________
City: _____________________________________ State: ___________________________ Zip Code:_______________
___ Change my NAME to now appear on record as:
_________________________________________________________________________________________________
First Name Middle Name/Initial Last Name
One of the following documents must be attached to process change:
___ Court Order ____ Birth Certificate ____ Marriage License ____ Divorce Decree
Optional: Preferred name will appear in place of legal name on the Penguin Portal, Blackboard, and Starfish. No documentation required.
Preferred First Name:_____________________________________________________
___ Change my GENDER to now appear on record as: ____ MALE ____FEMALE
One of the following documents must be attached to process change:
___ Change order or birth certificate legalizing the change
___ Letter of Support from qualified mental health professional
___ Bureau of Motor Vehicles Declaration of Gender Change
___ Pre- or- post-operative documentation from qualified health care provider
I affirm that the information provided on this form is complete and true. I hereby authorize Youngstown State University to update the above changes to my record.
Student Signature:____________________________________________________________ Date:______________________________
For Office Use Only: Processed by:_____________
___ Changed in Banner Date: ____________________
___ Scanned to Banner via BDMS
Documentation Attached:
___ Copy of valid photo ID
___ Copy of legal document(s) supporting the change(s) when necessary Rev. 5/2/18