THE UNIVERSITY OF ROCHESTER
SCHOOL OF MEDICINE AND DENTISTRY

For M.D. Students or Graduates of the M.D. Program ONLY

CHANGE OF ADDRESS FORM

This form serves to officially notify the Medical School Registrar's Office that a student has changed their local or permanent address.

Student Name: _______________________________________________________

Student ID Number: _______________________________________________

Medical Center Box #: __________________________

Class of: _____________________________________


Are you changing your local or permanent address?
(circle one)



OLD ADDRESS: NEW ADDRESS:
__________________________________ OLD Address __________________________________ NEW Address
__________________________________ Street __________________________________ Street
__________________________________ Apt # __________________________________ Apt #
__________________________________ City                    State                    Zip __________________________________ City                    State                    Zip
__________________________________ Phone __________________________________ Phone




http://www.urmc.rochester.edu/smd/mdregistrar/forms/changeaddress.html;
8/97;lm; Last Updated: