Change of Personal Information Request From

CHANGE OF PERSONAL INFORMATION REQUEST FORM
Student Name*

First NameLast Name
Student ID #*
Date of Birth*

MonthDayYear
Date
Student Email Address:*
xxxxxxxxxx@student.potomac.edu
For address, phone, and email changes, please use your Student/Alumni Portal!
I would like to add/change the following information:
Enrollment Status change - Full time or Part time (option available for domestic students only)
Add Social Security Number:

YES
(Change will be made after a copy of the social security card is received by the Registrar’s Office)

Cancelof
Change Last Name Change

YES
from
to
(Change will be made after a proper documentation is received by the Registrar’s Office)

Cancelof
Change Middle Name Change

YES
from
to
(Change will be made after a proper documentation is received by the Registrar’s Office)

Cancelof
Change Marital Status:

YES
from
to
(Change will be made after a proper documentation is received by the Registrar’s Office)

Cancelof
Change Immigration Status:

YES
from
to
(Change will be made after a proper documentation is received by the Registrar’s Office)

Cancelof
By checking this box,

I understand that changes will be made after proper documentation is received by the Registrar’s Office, including but not limited to copy of social security card, marriage certificate, or government-issued photo ID. I hereby authorize University of the Potomac to make the above changes to my student account.
Signature*

Clear
Date*

MonthDayYear
Date
____________________________________________________________________

Office Use Only

UOTP Official: _____________________________________ Date: _____________

Printed Name/Signature
Should be Empty:

CHANGE OF PERSONAL INFORMATION REQUEST FORM