REV 03/12
LEGAL NAME CHANGE FORM
(Please mail completed form to your Human Resources Office
within thirty-one (31) days from the date of name change)
CCSNH Institution (check one):
SYS _______ GBCC ______ LRCC _______ MCC ________
NCC _______ NHTI _______ RVCC _______ WMCC ______
New Name:
_____________________________________________________________________________
Last First MI
Former Name:
_____________________________________________________________________________
Last First MI
Social Security Number (last four digits): XXX-XX-@@@@@@@@@@@@@@
Effective Date of Name Change: ___________________________
Reason for Name Change (check one):
r Legal Name Change (attach a copy of Court Document authorizing name change)
r Change in Marital Status (attach copy of Marriage Certicate/Divorce Decree)
_____________________________________________________________________________
Employee Signature Date
___ ___ ___ – ___ ___ ___ – ___ ___ ___ ___
Employee Contact Phone Number
click to sign
signature
click to edit
![]()
