Employee Information Change Form

Employee Information Change Form

To be completed by DPI Employee
Please use this form to make changes to your email, phone, address, name, etc. Once completed it will be submitted directly to the Human Resouces Operations and Compliance ("HROC") department. Someone may reach out for additional information, if necessary to make the change.
Date*

MonthDayYear
(Defaults to today’s date)
Your name:*

First NameLast Name
Your email address:*
example@gmail.com
What type of change do you need to make (choose all that apply)*

Home addressYour legal nameYour personal email addressYour contact phone numberOther
If you have other information to report or change, please use the Assistance Request Form.
New Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
New Email:*
example@example.com
New Legal Name:*

First NameMiddle NameLast Name
Use the 'upload' feature on this form to send a copy of the legal documents that reflect this name change.
- Social Security Card or valid Work Visa & state issued Drivers' License (must have both)
- US Passport
A representative from the HROC department will reach out to confirm this change with you and discuss any additional administrative items that are needed.
New Phone Number:*

Area CodePhone Number
Upload any supporting documents:

Browse Files

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My signature below confirms my intent to make these changes:
Signature

Clear
Should be Empty: