Employee Name And/or Address Change Form

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Employee Name and/or Address Change Form
Employee Profile
Employee Name: ____________________________________
Campus: ___________________________
Changes
(Please Select the Appropriate Box(es))
Name
:
Address:
*
*:
Proof of name change is required by the HR Department. You MUST bring proof of name change (Social Security Card with the changed name)
to the HR department or to your Principal.
Information
Types of Change
Old Information
New Information
________________________________________________________________________________________________________________________
Name
: _______________________________________________________
___________________________________________
Address
: _______________________________________________________
____________________________________________
_______________________________________________________
____________________________________________
Verification of Changes
I elect to
OPEN /
CLOSE public access to my home address, telephone number, Social Security number and information on
family members.
Employee Signature
Date
: _________________________________
: _________________________________
Your signature authorizes Harmony Public Schools to change your address with all of the companies that provide benefits to you through payroll
deduction.
Employee Name and/ or
Address Change Form Page 1 of 1
Form HR‐102

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