Office of Human Resources Form

Employee Change

Staff / Faculty / Student / Other - Non Employee

Employee Change Information

Select Employment Category:

Staff Faculty Student Other (Non-EE)

Change Reason: 

Employee ID:

 Org Unit (Dept):

Personal Data: Please Complete Applicable Fields
Title:  
Legal Last Name:  
First Name:  
Middle Name:  
  Nickname:  

Family Member/Dependents: No. Dependents:  

For more than Four Eligible Dependents, Please Attach List to Form.

Last Name

First Name

Relationship

DOB 

 

 

 

 

Preferred Last Name:

Suffix (Jr. Sr., II, etc.):

Birth Date (Req. Doc):

Highest Ed. Level: 

Marital Status:

Please Provide Emergency Contact Information 

Last Name:

 

Last Name:

First Name:

 

First Name:

Area Code/Phone:

 

Area Code/Phone:

Additional Personal Data:  Please Complete Applicable Fields
 Ethnic Origin:

  Military Status:
Ethnicity:

  Veteran Status:
 

 US Citizen   Yes    No

   If No, List Visa Status:
 

   Perm. Res. Country:

Addresses:  Please Complete Applicable Fields

Address Type:

 

Address Type:

Address:

 

Address:

City/County:

 

City/County:

State/Zip Code

 

   State/Zip Code:

Country:

 

Country:

Area Code/Phone:

 

 E-mail:

Area Code/Phone:

 

Preferred Contact:

Employee Signature:

 

    Date:

(Hand Written Please)

Please Return All Copies of Completed Form to Human Resources