EVERETT PUBLIC SCHOOLS

HUMAN RESOURCES DEPARTMENT

CHANGE OF ADDRESS / NAME FORM

 

 

Name: __     __________________________    Employee ID:__________

(Please Print Name)

 

 

Location: __    ______             

 

 

My new mailing address and phone number for any future correspondence is:

 

Address: ___     _________________

 

City: __     _____________ State:_     ____ Zip:__     __________

 

 

Phone number: __     ____    ______ Effective date: __     _________

 

E-Mail: ___       _________________

 

 

My new name for any future correspondence is:

(name changes cannot be completed until Human Resources has a copy of your new signed social security card)

 

Previous name: __     ________________________________

 

New name*: __     ___________________________________

 

* Attach a copy of your new social security card

 

 

Signature: _______________________________________

 

Date: ___________________________________________