Banner ID Number: ______________________________________________________
or Social Security Number: ________________________________________________
Last Name: _____________________________________________________________
First Name: ____________________________________ M.I. _____________________
Home Address: __________________________________________________________
City: _________________________________ State: ___________ Zip: _____________
Daytime Phone (including area code): _________________
Cell Phone: ______________________
Email Address: ____________________________________
Course # &
Fax completed form to the Office of Registration and Records at
Mail completed form to the Office of Registration and Records, The College at Brockport, 350 New Campus Drive, Brockport, NY, 14420-2966.
Please call the Office of Registration and Records at (585) 395-2531 to confirm receipt of your form.
New-to-the College students must submit The College at Brockport New Student Information Form to the Office of Special Sessions & Programs before your registration can be processed.