Request To Change Nih Directory Information To Add, Change, Or Delete A Listing
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1
2Please make the following changes to:
Request to Change NIH Directory Information
Personnel Alphabetical Listing
To Add, Change, or Delete a Listing
Organizational Listing (name changes only)
Please have your Administrative Officer sign this form before sending. If item 12 is incomplete, the updating process will be
slowed. See your Administrative Officer for changes to the Yellow Pages. Please see the Privacy Act Notification Statement
on the reverse of this form.
1.
NAME as you want it to appear in the directory
2.
PHONE NO.
Yes
LAST:
FIRST:
MI:
DR.?
No
3.
FAX NO.
4.
MAIL STOP
5.
BUILDING
6.
ROOM NO.
8.
ORGANIZATION. You must use the abbreviations (developed especially for the Directory) listed in the front of your ICD
7.
SOCIAL SECURITY NO.
section of the NIH Telephone Directory.
9. NAME as it is CURRENTLY listed in the Directory (For name change only)
REMARKS OR OTHER
10.
Yes
INFORMATION
LAST:
FIRST:
MI:
DR.?
No
11. ACTION REQUESTED (check one)
Add to listing
Change existing listing
Left NIH
Retired
Deceased
Delete from listing. Check reason:
12. APPROVED BY ADMIN. OFFICER (Signature and phone no.)
Date
NIH 433 (12/12) FRONT
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