Rev.1/9/18
Employee Information & Change Form
Please select one: New Employee Change
Full Legal Name: Date of Birth
Name Change: (Former Name)
Please note name changes will prompt a change in your email address. Legal documentation is required.
Street Address:
Mailing Address:
(please complete if different from street address)
Home Phone No. Cell Phone No.
In case of Emergency please contact:
Emergency Contact Phone:
Spouse In-law Parent Friend Other
PLEASE NOTE: DUE TO THE COLLEGE’S RED FLAG POLICY, THIS FORM MUST BE
RETURNED TO HUMAN RESOUCES OR DESIGNATED REPRESENATIVE ON THE
NEWBURGH CAMPUS IN PERSON WITH THE APPROPRIATE ID
Signature Date
Please do not mark below this line - Office Use Only
Department: Ext & Build/Room
Start Date: Title: A #
___ Banner
___ Access
___ File
___ Academic Affairs (Faculty Changes)
___ Payroll (all Changes)
___ President’s Office (FT Changes)
