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Local Address 

 Street Line 1  : 



 Street Line 2  : 



 City           : 



 State/Zip      : 

 



 Phone Number   : 



 Effective Date : 



 Expiration Date: 



 Restricted Address      :

NO

YES

 Restricted Phone #      :

NO

YES

 Restricted Email Address:

NO

YES

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University of Pennsylvania
Comments to:
Office of the University Registrar
Room 221 Franklin Building
Philadelphia, PA 19104-6291
Phone: (215) 898-7511 FAX: (215) 573-2076
Division of VPUL - Office of Student Information & Systems
regist@pobox.upenn.edu
Document: 0201