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First name*

Last name*

myWSU ID*

Date of birthmm/dd/yyyy

Email address

Phone numberxxx-xxx-xxxx

If you checked other on the question above, please indicate below

If you plan on attending another college or university, where will you be attending?

College / school name

College / school city

College / school state

If you need to provide additional clarification, or have questions about these changes, please enter that information below.

Certification / Submit

I certify that the information provided, including my academic history, is complete and correct, and I understand that the submission of false information is grounds for denial of my application, withdrawal of any offer of acceptance or scholarships, cancellation of enrollment or any appropriate disciplinary action. I authorize Wichita State University to verify the information that has been provided.

Name of person submitting this form*

Phone number, if different from the studentxxx-xxx-xxxx

Email address, if different from the student