Southern University Human Resources
Address/Name Change Form
Thank you for typing or printing all information except your signature.
Social Security Number
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Employee’s Name
Employee’s Signature
Date:
Work
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Home
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Cell
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Other
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Please indicate if home and/or cellular telephone number is private:
Request will
not
be processed if Post Office Box is the only address submitted!
Home Address:
Number & Street
Apartment No., if any
City
State
Zip
Select requested change: correspondence only check only correspondence & check
Mailing Address:
Number & Street
Apartment No., if any
City
State
Zip
Select requested change: correspondence only check only correspondence & check
Request will not be processed without valid documentation
Employee’s Previous Name
Reason for name change: Marriage requires copy of marriage license and social security card stating married name.
Divorce requires copy of the divorce decree.
Misspelled name requires certified birth certificate or valid social security card.
Any other reason requires applicable documentation such as court order.
You may submit this completed form:
In Person/Campus Mail Federal Mail
Human Resources Human Resources
First Floor Leonard C. Barnes Admin. Bldg.
Leonard C. Barnes Administration Building 3050 Martin Luther King Jr. Dr.
Phone: 318-670-9351 Shreveport, LA 71107
Fax: 318-676-5496
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