Human Resources/Payroll Services
Change of Address

Employee Name:
Social Security Number:
Old Address:
New Address:
Telephone Number:
Effective Date of Change:

To be completed by Human Resources
Human Resources Notified By:  Telephone
 In Person
Date Notified:
Date Entered in HRS System:
Date BC/BS Notified:
Date of Retirement System Action:  


HR Employee: 

Payroll Employee: 
(Routing Procedure: 1. HR, enter system 2. Payroll, Update neccesary into 3. HR, call up for weekly notification of BC/BS & Retirement)

Revised 14 MARCH 2001 mcr