Fill out the following information and click 'Submit'.
All fields are required in the first section.

This section requires information from either your original Application or a previous Change Of Information Form and is for the purpose of verifying that you are the original applicant.

If all you are changing is your Email Address, then please do not use this form.
Use a

 form instead.


WARNING for SLBC Moodle students:
If you submitted a multi-part Application form and were issued a
User Name and Password DO NOT USE THIS FORM! You are
registered with our automated site at
and all of your tests, forms, and other communications must
be with that site directly and not through this current site.
If you are a SLBC Moodle student and submit this form,
it will be Disallowed and discarded and cannot be
placed in your Moodle-enabled academic file.

Only those students who were NOT ISSUED a User Name
and Password are allowed to use this current form.

*Student full name (from Application):
*Email address currently registered for you with us:
*Verify Email address currently registered for you with us:
*Date of your original Application:
*Your birthdate:
*Country of your birth: Other:  
*City of Birth:
*Name of your High School or place of GED
*Name of your Pastor from your original Application form:

(If you did not have a pastor listed on your original Application, then enter NONE in this field.)

In the following field you will input the information to be changed.
List name of the change and then the information to be changed.
Only list the information that has changed.
New Pastor name: John Smith
Name of New Church: New Testament Church of Smithville
New Church Address: 3768 North Smith St., Smithville, NY
Student New Address: 4300 South Smith St., Smithville, NY

Also include any Comments that you think are necessary.


*Comments and/or Changes:
*Information affirmation:
Yes, the information is true to the best of my knowledge.