Student Change of Information Form

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:______________________________