Student Address Update Form

Date:

First Name*

Last Name*

Student ID Number

Email Address

Anticipated Graduation Date (mm/dd/yyyy)

Indicate Current Semester

Current School Year (if already enrolled)

Number of Hours Enrolled

Complete Enrollment History (include terms)

Graduated Year

How will this verification be delivered?

Street Address (if mailed)

Address Line 2

City

State / Province / Region

Postal Code / Zip Code

Country

Phone Number

I authorize Voorhees University to verify all information contained in my academic record and hereby release Voorhees University and its employees from any liability for issuing this information.

I represent that I am the applicant and my typed name below authorizes the same as my signature.

Requestor

Guardian

Student

Requestor's Name

Requestor's Phone Number