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 They will contact you when the information has been updated, and/or if they have any questions or requests for clarification.

Thank you.

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

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

(If changed for official purposes):

(If changed for official purposes)

For correspondence only. For international numbers, please include country code.

For correspondence only.

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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