Personal Data Form
Western University
Human Resources Support Services Building - Room 4159
London, ON N6A 3K7
Tel: 519-661-2194 Fax: 519-661-4104
This form is to be used by individuals who need to change some details regarding their personal information which is used by Human Resources.
Data collected here will be disclosed to other Western departments as necessary to administer your employment relationship with Western. Those
departments include but are not limited to the Office of the Registrar, Financial Services, Faculty Relations, Western Libraries, Western Technology
Services, Parking Services, Campus Meal Plan, Campus Recreation, and Advancement Services.
The collection and disclosure of this personal information is governed by Western’s administrative policy
1.23 GUIDELINES ON ACCESS TO
INFORMATION AND PROTECTION OF PRIVACY.
Please note that in the interest of protecting your personal financial accounts, banking information used to directly deposit
payments to you from Western must be submitted and changed using the employee self-service application My Human
Resources. Please log in using your Western User ID and password and provide bank account information.
Employee Information
NAME WESTERN ID NUMBER STUDENT NUMBER
PHONE NUMBER
Home Cell SIN
EFFECTIVE DATE OF CHANGE
YYYY - MM - DD
Name Change
REASON FOR CHANGE
Marital Status Change Legal Name Change
Please attach two pieces of identification to support the change, one being
a photo ID (not required for spelling corrections or Preferred First Name).
Correct Spelling Preferred First Name
PREVIOUS LEGAL NAME
First
Middle Last
NEW LEGAL NAME
First Middle Last
PREFERRED/CHOSEN First
Your preferred or chosen first name is the first name you commonly go by, and differs from your legal first
name. Limited to specific services where legal name is not required e.g. Western ONECard (replacement
fee may apply); Western email & OWL Display Name. My Human Resources will display your legal name.
Address Change
COUNTRY ADDRESS
CITY PROVINCE/STATE POSTAL CODE/ZIP
Correction / Revision
REVISED
BIRTH DATE
YYYY - MM - DD
Please attach two pieces of identification to support the change, one being a photo ID.
NEW SOCIAL INSURANCE NUMBER
Please attach copy of
new Social Insurance
Number.
PREVIOUS SIN
Signature Date
Updated Feb 2019 Human Resource Record
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