Change of Information Form
Please complete all applicable information and return the signed form to the Human Resource Office,
Wheeling Campus, Room 125, 1704 Market Street, Wheeling, WV 26003
Name Address
Telephone Number
What information would you like us to change?
Please submit your changes below:
(Please provide the Human Resource Office documentation for name changes. ( Marriage License, Court Order)
I authorize the release of this information to the Human Resource Office and the Accounts Payable
Office for Travel reimbursement.
_______________________________________________ __________________________
Signature Date
There may be other documents that need to be completed. To notify your benefit carriers of this
change, please check with the HR Office for additional directions.
Banner EPICS
WV-11
Name change from: to:
New Address:
cc: Accounts Payable (date____________)
Employee Name:
City Zip CodeState
Telephone:
For Human Resource Office Use Only:
Home Number
Cellular Number
Effective Date of Change:
Personnel Program (Name Only)
Social Security #:
