ARKANSAS TECH UNIVERSITY Russellville:
PERSONNEL DATA CHANGE/UPDATE FORM Ozark Campus:
**CERTIFIED DOCUMENTATION IS REQUIRED WHEN MAKING CHANGES TO NAME, SSN, AND MARITAL STATUS.
Documentation and form should be brought to Human Resources, Brown Hall Suite 434, for updating. Acceptable documents for name changes include court
documents, Social Security Card, and Driver’s License. Social Security card is required to update name changes.
Employee’s Name: Banner T Number:
If name change, please provide previous name: ______________________________________________________ (Documentation Required)
ADDRESS/PHONE NUMBER CHANGE
Mailing Address: City: State: Zip Code:
Home Phone Number: □ Primary □ Unlisted □
Cell Phone
CITIZENSHIP OR MARITAL STATUS CHANGE (Documentation Required)
Citizenship: □ Citizen □ Non-Citizen □ Resident Alien
Marital Status: □ Married □ Divorced □ Single □ Widowed
EMERGENCY CONTACT CHANGE
Last Name: First Name:
Relationship: Phone #:
Address:
Street City, State Zip
ADDING DEPENDENTS (
to add eligible dependents: Spouse, Children)
Legal Full Name: Relationship to Employee:
Date of Birth: Gender: □ Male □
Female
Attending College: □ Yes □ No
Legal Full Name: Relationship to Employee:
Date of Birth: Gender: □ Male □
Female
Attending College: □ Yes □ No
FOR HUMAN RESOURCES USE ONLY
DATE HUMAN RESOURCES RECEIVED:
DATE BANNER SYSTEM UPDATED:
PPAIDEN (Name, Address, Citizen/Marital status and/or EM) PEAEMPL (SSC/Name Change) PDABENE (Dependents)
BENEFIT SYSTEMS TO UPDATE FOR NAME/ADDRESS CHANGES
BCBS____________ HUMANA____________ USABLE____________ AF____________ APERS____________
12/10/14
