Personal Information/Emergency Contact - Virginia Tax



PERSONAL INFORMATION/EMERGENCY CONTACT FORMPlease complete this form in its entirety to ensure accuracy of personnel recordsEffective Date: FORMTEXT ?????Form Type: FORMCHECKBOX Original FORMCHECKBOX ChangeEmployment Status: FORMCHECKBOX Classified FORMCHECKBOX WagePERSONAL INFORMATION:Employee ID #: FORMTEXT ?????Name: FORMTEXT ????? FORMTEXT ????? FORMTEXT ? FORMTEXT ??? Last First M.I. SuffixNew Name*: FORMTEXT ????? FORMTEXT ????? FORMTEXT ? FORMTEXT ??? Last First M.I. Suffix*Name changes require an updated social security card and a completed VRS-48 form.Home Address: FORMTEXT ?????Home #: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMTEXT ?? FORMTEXT ?????Work #: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????CityStateZipCell #: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????EMERGENCY CONTACTS: In the event of an emergency, please contact the following person(s):Primary Contact (complete FULLY):Secondary Contact (optional):Name: FORMTEXT ?????Name: FORMTEXT ?????Address1: FORMTEXT ?????Home Phone: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????Address2: FORMTEXT ?????Work Phone: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????City, State, Zip: FORMTEXT ?????Relationship: FORMTEXT ?????Home Phone: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????Work Phone: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????Relationship: FORMTEXT ?????Special medical instructions (optional): FORMTEXT ????? FORMTEXT ?????Signature FORMTEXT ?????Date FORMTEXT ????? *This form allows for electronic signature*Send completed forms to Bente Clatchey in Human Resources via:Fax: (804) 786-3626;Email: bente.clatchey@tax.; or Mail: 600 East Main Street, 23rd Floor, Richmond, VA 23219. ................
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