PSU FORM 102 Revised 2002

DATE: ____________

NOTICE OF CHANGED NAME

(DUE TO MARRIAGE )

DIVISION NAME/ CODE: _______________________________

STATION NAME: _______________________________

(School for Secondary/District for Elementary)

STATION CODE: ( 3 digits) ______________________________

EMPLOYEE NUMBER: ______________________________

EMPLOYEEE NAME: ______________________________

SIGNATURE : ______________________________

OLD NAME :
LAST NAME FIRST NAME MIDDLE NAME

MARRIED NAME:

LAST NAME FIRST NAME MIDDLE NAME

PLEASE ATTACH HEREWITH THE FOLLOWING SUPPORTING DOCUMENTS:

1. ONE CERTIFIED TRUE COPY OF MARRIAGE CERTIFICATE

2. SPECIAL ORDER – CHANGED NAME
3. LATEST PAYSLIP

(Please submit in 2 copies)

CERTIFIED CORRECT:

_____________________
Principal/District Supervisor