Former Employee Change Form

Dear Former Employee,

Berkeley Lab has created a form to record specific changes that may have occurred in your life after leaving the Laboratory. The fields below reflect the data that can be updated post-employment. This form is voluntary and not required.

Please complete this form to indicate the updates that you would like to be made in Berkeley Lab's system. Please note that gender transitions will be recorded in Berkeley Lab's internal system only, not external systems (such as UC benefits).

For any questions, please contact Berkeley Lab's HR Shared Services Center at (510) 486-4772 or email hrsc@lbl.gov. They will contact you when the information has been updated, and/or if they have any questions or requests for clarification.

Thank you.

First Name at Berkeley Lab*
(As used for official purposes while employed at Berkeley Lab):

Last Name at Berkeley Lab*
(As used for official purposes while employed at Berkeley Lab):

Berkeley Lab Employee ID #

Date of Birth*

Current First Name*
(If changed for official purposes):

Current Last Name*
(If changed for official purposes)

Gender

Current Phone Number*
For correspondence only. For international numbers, please include country code.

Current Email Address*
For correspondence only.

Current Address (Number, Street)

Current Address (Apt #, Unit #)

City

State

Zip Code

Country

Confirm the accuracy of the information provided*
By entering your name below, you are signing this Former Employee Change Form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form and that by this electronic signature, you certify that the information provided on and in connection with the Former Employee Change Form is true, accurate and complete.

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Email address