2. First Name
3. Last Name
5. Last Four Digits of Social Security Number
6. Effective Date of Address Change
   Effective Date of Address Change
8. Change of Address Form For

   1. Civil Service Examination Application
   2. Part-Time Applicant
   3. Civil Service Eligible List

   Check All Appropriate Boxes That Apply
10. Old Address
12. City
13. State
14. Zip Code
16. New Address
18. City
19. State
20. Zip Code
22. For Exams Only, Please Provide All Requested Information to Insure an Accurate Address Change
24. I Have Signed Up for the Following Exams
26. I Have Taken the Following Exams
28. Exam Number & Title
30. Candidate Signature*
    By typing your name into this field you authorize Yates County to consider this an electronic signature.
31. Date
    Date
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field