NUID#

Today's Date

New ChangeType of Request:

PERSONAL INFORMATION FORM

If change, effective date of change:

First Name Middle Last Name Suffix Preferred Name

E-mail Type E-mail Address

(Mail Directory Only)

Male

Female

Gender

Marital StatusBirth Date Soc. Sec. Number Highest Education Level

YOUR NAME

YOUR HOME ADDRESS (Changes can be made electronically via Employee Self Service)

CONTACT INFORMATION (Changes can be made

electronically via Banner HR)

YOUR IDENTITY

Primary Contact Name

Relationship

Yes NoAddress same as yours?

Contact Name

Yes NoAddress same as yours?

EMERGENCY CONTACTS (Please provide at least one. Changes can be made electronically via Employee Self Service)

HRM Customer Service Center250 Columbus PlaceBoston, MA 02115

617-373-2230 1/30/2012

New employees: use this form to provide new or changed information for your HR/Payroll record. Complete the formelectronically, print and sign it and send to the HRM Customer Service Center, 250 Columbus Place.Current employees: use this form to change name and identity information. All other fields can be updated inBanner HR

Relationship

Your Signature

Street Address

City State Zip Code

Date

** If change, new name** If name has changed, you must present Legal Name Change

Document or Social Security Card in person along with this form. If this is a Legal name change, please provide a copy for your Division contact or Deans Office so that they may also update their records.

Address Line 2

Street Address

City State Zip Code

Street Address

City State Zip Code

Address if your answer is no: Address if your answer is no:

Highest Degree: Major Date Acquired School