Name Change Request Form

Section 1: Employee Information

Request Date: * +

Effective Date: * +

Employee's Name: *

Employee lD:

Employee's Email: *

Section 2: Name Change Information

Old Last Name:

New Last Name:

Change Name on User Account(s): Select All that Apply.

Notes:

A copy of your new social security card is required with a name change and should be provided to HR.

If you are enrolled in life insurance or health insurance, please log in to EASE and update your beneficiaries and make requests for any health insurance changes.

If you are a SURS participant you must complete their name change form.

Comments:

Is this form ready to submit (click box and select Submit button)?

Yes

Section 3: Human Resources Office Use Only

Update Admin Systems

Update SURS Account (if applicable)

Update address on health insurance website (if applicable)

Submit to IT ONLY if there is a question to change account name(s)

Yes

Section 4: IT Office Use Only (Network/Phone/Email/Canvas Name Changes)

New User Name:

Is name changed on phone?

Yes

N/A

Is this section complete (click box and select the Submit button)?

Yes

Section 6: IT Office Use Only (MySRC/Administrative System Name Changes)

New User Name:

Password:

IT Comments:

Is form complete (click box and select Submit button)?

Final Submit

Email	Network
My SRC	Canvas
Telephone	CX