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Name or Address Change Form
* * * ATTENTION! This form will not be sent if fields are left blank in this section. * * *
Are you a KUMC university employee? Yes No
Current Name: (last, first, mi)
Employee's Last 4 digits of Social Security Number:
Work Phone Number:
Employee's Email Address:
New Name: (last, first, mi)
NOTE: You must provide an updated social security card for verification of name change in person to Employment (1044 Delp) to have your signed Social Security Card scanned.
If you are requesting an address change, why are you doing so?Address CorrectionMovedNo longer an employee* *If you select this option, please do not close your bank account(s) until after you receive your last paycheck.
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County in Which You Reside:
Home Phone Number: (ex: 913-642-5555)
If you have any questions about completing this form, contact Erica Rogers at 913-588-5099.
The University of Kansas Medical Center prohibits discrimination on the basis of race, color, ethnicity, religion, sex, national origin, age, ancestry, disability, status as a veteran, sexual orientation, marital status, parental status, gender identity, gender expression and genetic information in the University's programs and activities. The following office has been designated to handle inquiries regarding the non-discrimination policies: The University of Kansas Medical Center Department of Equal Employment Opportunity, 1054 Wescoe, 3901 Rainbow Blvd., Kansas City, Kan., 66160, 913-588-5088.