Address Change Form

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:


32. 1. Receive email copy
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field