Rev. 09/11
RIVERSIDE COMMUNITY COLLEGE DISTRICT
Name/Address Change Form
for
District and Student Employees
Riv MV Nor Dist
Legal Name:
(Please list name exactly as it appears on your Social Security Card)
Former Name:
(This is only necessary if you are making a name change)
Preferred Name: Social Security Number: XXX-XX-
(Last 4 digits)
New Address:
(Street)
(City) (State) (Zip)
Telephone:
(Home) (Work)
What Department do you work in?
Do you wish for this information to be released to your department/office? Yes No
Information to be confidential: Yes No
Check all that apply to you as an employee:
Full-Time Faculty/Counselor/Librarian
Management/Supervisor
Classified/Confidential
Child Development
Short-Term/Substitute
Part-Time Faculty/Counselor/Librarian
Member of the RCC Foundation
Student Employment
PROCEDURES
District Employees - Original Name/Address Change
Form must be submitted to the Diversity & Human
Resources Office along with a new Social Security Card
showing new name (SS Card for name changes only).
Student Employees - Original Name/Address Change
Form must be submitted to the Student Employment Office
along with a new Social Security Card showing new name
(SS Card for name changes only).
For Diversity & Human Resources/Admissions & Records Use Only
Changes entered on: Completed by:
Date Name
Distribution: _____ Department/Student Employment
_____ Diversity & Human Resources (District Employees Only)
_____ Admissions & Records (Student Employees Only)
_____ Payroll
_____ Benefits Specialist
_____ Purchasing Manager
Si
nature: Date:
Name Change
Address Change
(Check one or both if applicable)
Original: Diversity & Human Resources Office or Student Employment Office
cc: Payroll, Employee
