Current Name: _________________________________________________________________

Previous Name(s): ______________________________________________________________

Social Security Number: __________- __________ - __________

Please note that changing your address to an in-district address will not automatically change your residency or tuition status. See Residency Information or visit the Admissions Office in Vermilion Hall (217-443-8801) for residency information.

NEW ADDRESS:

_________________________________________________________________
Street

_________________________________________________________________
City                                                   State                                                 Zip Code

_________________________________________________________________
Area Code           Phone Number

OLD ADDRESS:

_________________________________________________________________
Street

_________________________________________________________________
City                                                   State                                                 Zip Code

_________________________________________________________________
Area Code           Phone Number

Student's Signature: _________________________________________________

Received By: ____________________           Date: ________________________