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Series 401.6P - Employee Change of Name, Address or Telephone Number

When an employee changes his or her name, address or telephone number, the employee is required to report changes to the Human Resources Department.

  • If you are completing this form because your name is changing, you will need to visit your local Social Security Administration office BEFORE you complete this form and get your name changed on your Social Security Card or your employer CANNOT and WILL NOT begin using your new name.
  • If you are changing your insurance beneficiary, come to the District Office and fill out the necessary forms. This form is for District Office use and does not change your records at the school.
  • If you are using this form to also notify your school administration of any changes, include the correct email address for the individual who takes care of this information at your school’s office in the "Additional addressee's email" field below.

Name (print)__________________________________________________________________

Employee number _______________

If name changed recently, former name __________________________________________


Primary phone                                                        □  Land line           □  Mobile

Mobile phone                                                             

                        (if different from primary phone)


Employed as a                                                         at                                           

Date                                 Signature                                                                      

Additional addressee’s email                                                                                   

Return this form to the Human Resources Department.