Personal Information/Emergency Contact - Virginia Tax
PERSONAL INFORMATION/EMERGENCY CONTACT FORM
Please complete this form in its entirety to ensure accuracy of personnel records
|Effective Date: | |Form Type: Original Change |
| |Employment Status: Classified Wage |
|PERSONAL INFORMATION: |Employee ID #: | |
|Name: | | | | |
Last First M.I. Suffix
|New Name*: | | | | |
| | | | | |
Last First M.I. Suffix
*Name changes require an updated social security card and a completed VRS-48 form.
|Home Address: | |Home #: |( ) - |
| | | | |Work #: |( ) - |
| |City |State |Zip |Cell #: |( ) - |
EMERGENCY CONTACTS: In the event of an emergency, please contact the following person(s):
Primary Contact (complete FULLY): Secondary Contact (optional):
|Name: | |Name: | |
|Address1: | |Home Phone: |( ) - |
|Address2: | |Work Phone: |( ) - |
|City, State, Zip: | |Relationship: | |
|Home Phone: |( ) - | | |
|Work Phone: |( ) - | | |
|Relationship: | | | |
|Special medical instructions (optional): | |
| |
|Signature | | |Date | |
*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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