Clark
University Registrar’s Office
Change of Address/Telephone Request
Name
_______________________________________
Please
change my address(s) and telephone number(s) as noted below: (Note: the campus mailbox
or department box may not be used as a permanent address.)
Type
of Address:
|
_____ |
Permanent (usually
parent/home address, unless you are an independent student) |
|
_____ |
Off Campus-Local
(immediate Worcester area while attending Clark) |
|
_____ |
Billing |
|
_____ |
Temporary (usually
summer or study-abroad address, only valid for a specified period - please
include dates) From __________ To __________ |
Street ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ City ___________________________________________________________________ State ___________________________________________________________________ Zip ___________________________________________________________________ Tel. ___________________________________________________________________ Signature _____________________________________________________ Date ______________