Personal Information Change Form

All personal information obtained on this form will be held confidential by the Human Resources Office

Name Name First Last
Your Email Address
Last 4 of Social Security Number
Effective Date of Change or Correction (Enter todays date if you would like this changed ASAP) Effective Date of Change or Correction
(Enter todays date if you would like this changed ASAP) / MM / DD YYYY
What information needs to be corrected or changed?
(Choose as many as apply)

What information needs to be corrected or changed? (Choose as many as apply) Name (Legal or Choosen) Date of Birth Citizenship Status Sex Gender Identity Ethnicity or Race Disability Status Veteran or Military Status Education
Legal Name Legal Name First Last
If changing legal name you must provide Human Resources with a copy of your updated Social Security Card. Call x2126 for questions.
Chosen Name Chosen Name First Last
Correct Date of Birth Correct Date of Birth / MM / DD YYYY
U.S Citizen

U.S Citizen Yes No
Non-Citizenship Type

Non-Citizenship Type Permanent Resident Conditional Permanent Resident Non-Citizen w/Visa Non-Citizen living and working outside US Refugee or Political Asylum Other
Country of Citizenship
Country of Birth
Visa Type
Visa Expiration Date Visa Expiration Date / MM / DD YYYY
Sex

Sex Male Female
Gender Identity

Gender Identity Male Female Non-Binary
Hispanic

Hispanic Yes No
Race

Race American Indian or Alaska Native Native Hawaiian or Pacific Islanders Asian Black or African White
Disability Status

Disability Status Yes, I have a disability (or previously had a disabilility) No, I don't have a disability I don't wish to answer
Veteran

Veteran Yes No
Military Status

Military Status None Active Reserve National Gaurd Active Active Military Duty
Veteran Type

Veteran Type Active Duty Wartime or Campaign Badge Veteran Armed Forces Service Medal Veteran Disabled Veteran Other type of Veteran
Military Separation Date Military Separation Date / MM / DD YYYY
Highest Education Level

Highest Education Level Less Than High School High School, some additional training High School Graduate or GED Technical School Associate's Degree Bachelor's Degree Some Graduate Work Master's Degree Doctoral Degree Professional Degree
Degree Award Date Degree Award Date / MM / DD YYYY
University of Highest Degree
By signing below, I am authorizing the HR office to make the noted changes to my personnel record. I understand that depending on the change being requested, additional action and/or documentation may be required prior to the changes being made.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.