Please complete the following information and provide any required documentation for changes. If you are providing legal or identity
documentation, please deliver this form in person. Photo identification must have a clearly reproduced picture to be considered valid when
provided. Please allow 3-4 business days for processing. Only complete the areas below that you are seeking to change.
Current Name
First Name: Last Name: Middle Initial:
1) Address Change
City
State
Zip Code
Country (If other than USA)
Telephone Number
2) Legal (Of Record) Name/Gender Change
For your protection, SUNY Orange requires documentation for any LEGAL name or gender changes.
New Legal Name:
Legal Gender Change
☐
Male
Requesting Email Address/Username Change?
3) Preferred Name Change
SUNY Orange recognizes the needs of employees who wish to be identified by a name or gender identity that differs from their legal status. We are
also committed to protecting employee privacy in order to ensure that employees are treated in a manner consistent with their identity.
New Preferred Name: Former Name:
Documentation Required for LEGAL (Of Record) Name and Gender Changes
To legally change your name or gender, you must provide two forms of identification. Both forms of ID must provide your new name and/or gender.
At least one form
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SUNY ORANGE OFFICE OF HUMAN RESOURCES USE ONLY
Documentation Provided (Check All That Apply)
☐
Court Order ☐ Divorce Documents ☐ Birth Certificate ☐ Marriage Certificate ☐ Naturalization Documents ☐Passport ☐SSN/Card
☐
Driver’s License ☐US State-issued ID card (Non-Driver ID) ☐Other Legal Documentation:
Documentation Reviewed and Processed By: Date:
Signature of Employee A signature is required for ALL changes.
Personal Data Change Request
HR USE ONLY: ___ Banner ____ Access ____ RISK Mgmt (benefits only) ____ Payroll Verified by: ________________
Street Address
Emergency Contact
Emergency Contact Telephone
Spouse Parent
In-law
Friend
Other
_________________
Emergency contact relationship:
click to sign
signature
click to edit
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