ADDRESS / NAME CHANGE FORM
Please complete the top portion of this form, sign and return it to the Human Resources Manager in District Office.

Name: ____________________________________ Effective Date: ________
Check all that apply:
□	Name Change*                                                                 
□	Address Change
□	Phone Change
	□	Active Employee
□	Former Employee
□	Retiree	
*submit new social security card and driver’s license (with marriage license or divorce decree if applicable)
*if you need to add a dependent to health insurance, please fill out a new health insurance enrollment form

                 CHANGED FROM:                                                      CHANGED TO:
Name:  _______________________
Address: ______________________
____________________________
Phone (C): _____________________
Phone (H): ____________________
	Name:  _______________________
Address: ______________________
____________________________
Phone (C): _____________________
Phone (H): ____________________	

Employee’s signature: ____________________________ Date: ________
**For Office Use Only**

___ Human Resources
___ Email confirmation to employee
___District Clerk (email to technology & building office)
___Benefits
___ Payroll/Payroll File

____