CHANGE OF ADDRESS AND/OR PHONE

This form is for address and/or phone changes ONLY.

If you have changed your name, please use the NAME CHANGE form, not this form.

IMPORTANT: YOU MUST ALSO CONTACT THE BENEFITS OFFICE for instructions on what is needed for your medical and/or life insurance.

Name Name First Last
WARNING: If you have changed your name, STOP HERE.
DO NOT COMPLETE THIS FORM.
Please contact the Payroll Specialist in the Treasurer's Office or use the NAME CHANGE form here: https://treasurer.bcsoh.org/view.php?id=16419
School or Building
Position

Position Administrative Certified Custodian / Maintenance Food Service Mechanic Secretary / Paraprofessional Transportation Substitute Supplemental Contract - Coach Supplemental Contract - Other
Job Title
Certified Classified
Last 4 of Social Security #
Must be 4 characters. Currently Entered: 0 characters.
Effective Date of Change Effective Date of Change / MM / DD YYYY
PREVIOUS Address PREVIOUS Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
NEW Address NEW Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Previous Phone Previous Phone - ### - ### ####
New Phone New Phone - ### - ### ####
Mobile Home
Personal Email
Work Email
School District Number of Residence
Click to here to see list of School District Numbers

The school district number is required by law and can be obtained from a listing that is in each building or by calling the school district in which you reside.