Spreadsheet: 05a5aa99-87f1-44b4-9af2-1836429f860c
Sheet: Final

 |  |  |  |  |  | Current Action: |  |  |  |  |  |  |  |  |  | FORM HR96
 |  |  |  |  |  | [  ] Change of Address * |  | *Note:  A change of address can result in a change in local occupational tax
 |  |  |  |  |  | [  ] Change of Name ** |  | [  ] Military Service Information |  |  |  |  | [  ] New Hire |  | [  ] Change of Emergency Contact
 |  |  |  |  |  | Effective Date of Action:________________________________
Personal Information
 | Employee Name (First, Middle, Last):  *Current; or former in case of name change (new name indicated below)* |  |  |  |  |  |  |  |  |  |  | College: (Required)
 | Address (Street Address, City, State, [NAME]): Note: [NAME] cannot be entered as Home address, only a mailing address.  [NAME] have an actual street address for home address. |  |  |  |  |  |  |  |  |  |  | Employee ID#:
 | County of Residence: |  |  |  |  | Phone Number (Home or Cell): |  |  |  |  |  | [NAME]:
 |  |  |  |  |  | (                       )
 | **Check One: | o | I wish my name to be changed only in PeopleSoft for Human Resource and Student Affairs records.  My login ID and name display in global email will remain in the old/former name.
 |  | o | I wish my name to be changed to reflect my new last name in the global email display only.  My login ID will remain in the old/former name.
 |  | o | I wish my name to be changed to reflect my new last name in the global email display AND my login ID.
 | *** REMEMBER TO FILE AN ADDRESS CHANGE WITH YOUR RETIREMENT VENDORS and HEALTH and LIFE INSURANCE CARRIERS, if applicable.
Name Change
 | Presentation of a new Social Security card is required for a name change.  Please attach a photocopy of the new card issued in the new name.
 | New Name:
Emergency Contact Information
 | In the event of an emergency, or other situation, if we are unable to contact you directly KCTCS may need to contact a member of your family, or other individual(s).
 | Please list the names and appropriate contact information for two designated emergency contacts.
 | This information will only be used in the case of an emergency and will be retained for use only by the Human Resources office.
 | Contact Name #1 |  |  |  |  |  |  |  |  |  |  | Relationship:
 | Address (Street Address, City, State, [NAME]):
 | Home Phone Number: |  |  |  | Employer: |  |  |  | Work Phone Number: |  |  |  |  | Cell Phone Number:
 | (                       ) |  |  |  |  |  |  |  | (                       ) |  |  |  |  | (                       )
 | Contact Name #2 |  |  |  |  |  |  |  |  |  |  | Relationship:
 | Address (Street Address, City, State, [NAME]):
 | Home Phone Number: |  |  |  | Employer: |  |  |  | Work Phone Number: |  |  |  |  | Cell Phone Number:
 | (                       ) |  |  |  |  |  |  |  | (                       ) |  |  |  |  | (                       )
Military Status
 | Are you a member of the Armed Forces of the United States in any capacity which potentially makes you subject to a call to active duty (State or Federal)? |  |  |  |  |  |  |  |  |  | [  ] Yes     [  ] No
 | If so, please provide your unit designation (including your service e.g. National Guard or Coast Guard Reserve)
 | (Example:  2nd Battalion, [NAME], Kentucky Army National Guard)
 | Employee Signature |  |  | Date |  |  |  |  |  | Address change (only) to Accounting |  | Copy to Emer Contacts File |  |  | Entered in PS by | Date
 | *** Please send completed form to your college HR Office *** |  |  |  |  |  | Forward completed form, once entered, to KCTCS System HR for inclusion in permanent file
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | [NAME] Forms\PersDataForm,08.2010