Name/Address Change Form District and Student Employees

RIVERSIDE COMMUNITY COLLEGE DISTRICT
Reset Form
Name/Address Change Form
for
District and Student Employees
Riv  MV  Nor  Dist 
Legal Name:
Name Change
Address Change
(Please list name exactly as it appears on your Social Security Card)
Former Name:


(Check one or both if applicable)
(This is only necessary if you are making a name change)
Preferred Name:
Social Security Number: XXX-XX(Last 4 digits)
New Address:
(Street)
(City)
(State)
(Zip)
Telephone:
(Home)
(Work)
What Department do you work in?
Do you wish for this information to be released to your department/office?
Information to be confidential:
 Yes  No
 Yes  No
Check all that apply to you as an employee:
Full-Time Faculty/Counselor/Librarian
Management/Supervisor
Classified/Confidential
Child Development
Short-Term/Substitute
Part-Time Faculty/Counselor/Librarian
Member of the RCC Foundation
Student Employment








PROCEDURES
District Employees - Original Name/Address Change
Form must be submitted to the Diversity & Human
Resources Office along with a new Social Security Card
showing new name (SS Card for name changes only).
Student Employees - Original Name/Address Change
Form must be submitted to the Student Employment Office
along with a new Social Security Card showing new name
(SS Card for name changes only).
Signature:
Date:
For Diversity & Human Resources/Admissions & Records Use Only
Changes entered on:
Completed by:
Date
Distribution: _____
_____
_____
_____
_____
_____
Department/Student Employment
Diversity & Human Resources (District Employees Only)
Admissions & Records (Student Employees Only)
Payroll
Benefits Specialist
Purchasing Manager
Rev. 09/11
Original: Diversity & Human Resources Office or Student Employment Office
cc: Payroll, Employee
Name