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Codes for New General Education Curriculum

Address Change Form

Name Change Form

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Lead America Credits

THIS CHANGE OF STUDENT ADDRESS FORM CORRECTS ALL COLLEGE ADDRESSES

Return the signed form to the Registrar's Office by mail, Loras College, Mail #1, Dubuque, IA  52004-0178
or by facsimile (fax) (563) 588-4962

PLEASE PRINT!

Student Name: (last, first, middle)

Social Security Number:

Signature: Date:

The residing address is your address during the school year (August through May)

New Residing Address:

New City: State: Zip:

New Residing Telephone: ()

Effective Date (if address change is not effective immediately):  (month, day, year)

Complete this section if you have a new Permanent Address (if same as residing address, check here ____ )

New Address:

New City:State:  Zip:

New Permanent Telephone: ( )

Effective Date (if address change is not effective immediately):  (month, day, year)

Complete this section if your primary ____ Parent or ____ Guardian address has changed

Primary Parent or Guardian Name: (last, first, middle)

New Address:

New City:State:Zip:

New Telephone: ( )

Effective Date (if address change is not effective immediately):  (month, day, year)

Complete this section if your secondary Parent Address has changed.  If primary and secondary addresses are different, do both parties wish to receive mail? ___ yes  ___ no

Secondary Parent Name: (last, first, middle)

New Address:

New City: State: Zip:

New Telephone: ( )

Effective Date (if address change is not effective immediately):  (month, day, year)