Human Resources
Name/Address Change
Please complete this form, sign, date and return to Human Resources, SSC L134.
Name changes cannot be completed unless accompanied by a copy of marriage certificate or court document indicating the name is being changed.
All documents must be hand-carried into the office by the individual changing their name. No faxes or copies of documents will be accepted.
New First Name New MI New Last Name
Employee ID Number
Previous First Name Previous MI Previous Last Name
Employee ID Number
First Name MI Last Name
Please fill in new address.
New Mailing Address
City State Zip
Previous Mailing Address
City State Zip
Home Phone Number Cell Phone Number Work Phone Number
Signature Date
November 2018/PR
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