Full Text
DALLAS COUNTY OFFICE OF HUMAN RESOURCES Beth Deardorff, Director 902 COURT ST. ADEL, IA 50003 I PHONE [PHONE REDACTED] I WWW.DALLASCOUNTYIOWA.GOV EMPLOYEE CHANGE NOTICE FORM Please return to Human Resources at 902 Court Street Employee Name (currently on file): Check the appropriate box(es) reflecting a change: NAME CHANGE Change Name to: Please Note: All name changes must have a copy of the supporting documentation attached. (e.g. marriage certificate, divorce decree, etc.) ADDRESS CHANGE New Address: Additional Address Line: City: State: Zip: PHONE NUMBER(S) CHANGE Telephone Numbers: Cell: Home: EMAIL ADDRESS CHANGE New Email EMERGENCY CONTACT CHANGE Name: Address: City: State: Zip: Telephone Numbers: Home: Cell: Work: Relationship to Employee: (If there are more emergency contacts you would like to list, please fill out the Emergency Notification Form.) Effective Date of Change: Signature Date: Current Personal Email: