KINGSBOROUGH COMMUNITY COLLEGE
OF
THE CITY UNIVERSITY OF NEW YORK
CHANGE OF EMPLOYEE ADDRESS
INSTRUCTIONAL STAFF
PRINT NAME: _______________________________________________________ CD: __________________________
DOCUMENT NUMBER: _________________________ SOCIAL SECURITY NUMBER: _______________________
NEW ADDRESS: ____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
CITY: _________________ STATE: _________________ ZIP CODE:_______________ COUNTY*_______________
TELEPHONE #:____________________________ DEPARTMENT: __________________________________________
PREVIOUS NAME: (IF CHANGED) ____________________________________________________________________
DID YOU RESIDE IN THE CITY OF NEW YORK PRIOR TO CHANGE? ____ YES ____ NO (CHECK ONE)
SIGNATURE
DATE
__________________________
_________
A – ALBANY
B – BROOKLYN
C – COLUMBIA
D – DUTCHESS
E – DELAWARE
*COUNTY CODE KEY
F – WASH DC
M – MANHATTAN
G – GREENE
N – NASSAU
H – SCHOHARIE
O – ORANGE
K – ROCKLAND
P – PUTNAM
L – SULLIVAN
Q – QUEENS
R - RICHMOND
S – SUFFOLK
U – ULSTER
W – WESTCHESTER
X – BRONX
Z – OTHER
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ DO NOT WRITE BELOW THIS LINE _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
PREPARER
MANAGER/SUPERVISOR
KEY ENTRY OPERATOR
I certify that the above change is
supported by documentation on
file.
I certify that I have reviewed the
above change.
I certify that the above data was
entered into PMS.
Signature
Signature
Signature
Date
Date
Date
Distribution
White Copy - Dean of Faculty
Canary Copy – Payroll
Pink Copy – Human Resources