OFFICE OF THE REGISTRAR
THE UNIVERSITY OF NORTH CAROLINA AT PEMBROKE

ADDRESS/EMAIL/TELEPHONE CHANGE FORM

Directions: Please print, complete and return to the Office of the Registrar.

UNCP ID:_________________________ DATE:___________________________ DATE OF BIRTH:___________________________

Name:_________________________________________________________________________________________________________

                      First Name                                              Middle Name                                                 Last Name

 ADDRESS TYPES:  (Please use the address type and indicate this below.)

                                                DM (Diploma Mailing Address)            EC (Emergency Contact)

                                                LO (Local Mailing Address)                  MA (Permanent Mailing Address)

WK (Work Address for non-UNCP Employees)

Type: _______

New Address:___________________________________________________________________________________________________

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

Type: _______

New Address:___________________________________________________________________________________________________

                      ^{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.)

DM (Diploma Mailing Address Telephone)          EC (Emergency Contact Address Telephone)

LO (Local Address Telephone)                              MA (Mailing Address Telephone)                       CA (Campus Address Telephone)                

Type: _______                                                                                       Type: _______                                         

New Telephone:_____________________________                               New Telephone:___________________________________

Statement of Responsibility:

I assure 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:  Student_____________Faculty____________Staff ______________Alumni _____________Friend ___________

Return this form, with proper documentation, to the appropriate office below.

Faculty and Staff:  Human Resources, 347 Lumbee Hall

Students: Office of the Registrar, 133 Lumbee Hall

Alumni/Friends:  Office of Advancement, 442 Lumbee Hall, PO Box 1510 , Pembroke , NC 28372-1510

Prospective Students: Undergraduate – Admissions, 224 Lumbee Hall

Prospective Graduate Students:  Graduate Studies, 253 Lumbee Hall

FOR OFFICE USE ONLY

Routing Information:  HR to Registrar to Graduate (if needed)

                                   Graduate to Registrar

                                    Registrar to Graduate (if needed)

                                    Alumni to Registrar to Graduate (if needed)

Please return completed form to:

Office of the Registrar
PO Box 1510
Pembroke, NC 28372-1510

Office Location: Lumbee Hall, Room 133

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