CRANSTON PUBLIC SCHOOLS

 

EMPLOYEE CHANGE FORM

 

CHECK WHERE APPROPRIATE:

NAME          ADDRESS        PHONE

 

EMPLOYEE NUMBER: SOCIAL SECURITY NO:

 

NAME:        

                         LAST                                                             FIRST                                                      MAIDEN

 

ADDRESS:               

                                 STREET                                                      CITY                                             STATE             ZIP

 

PHONE:              UNLISTED?   YES  NO

 

POSITION: LOCATION:

SIGNATURE:   DATE:

 

*Please remember to change your name and/or address at the RI Employees’ Retirement System, 40 Fountain St., Providence, RI 02903

 

IF YOU HAVE HEALTH AND/OR DENTAL INSURANCE, PLEASE PROVIDE THE FOLLOWING:

 

HEALTH COMPANYHEALTH #

 

DELTA DENTAL #

 

***IF YOU HAVE A NAME CHANGE, PLEASE CONTACT DONNA-MARIE FRAPPIER (dfrappier@cpsed.net)

TO ALTER YOUR CPS E-MAIL ACCOUNT. IT IS IMPORTANT THAT WE HAVE A CORRECT E-MAIL ADDRESS

 SINCE MOST OF OUR COMMUNICATION IS DONE ELECTRONICALLY. WE ALSO NEED A COPY OF THE LEGAL

 PROOF OF THIS CHANGE***

__________________________________________________________________________

 

FOR OFFICE USE ONLY:

(INITIAL)

 

CHANGED IN COMPUTER_________

 

CHANGED ON LIFE CARD_________

 

CHANGED FILE__________________

 

MEDICAL/DENTAL________________