Text Box: GOVERNMENT OF GUAM CIVIL SERVICE COMMISSION KUMISION I SETBISION SIBIT 2nd Floor Hakubotan Bldg. E.T. Calvo Way, Tamuning 96913 P.O. Box 3156 Hagatna, Guam 96932 Tel: 647-1855/56 Fax: 647-1867 TO: Employee/Representative FROM: Executive Director SUBJECT: EMPLOYEE ADDRESS AND DISCLOUSURE FORM RE: Adverse Action/ EEO/ Grievance/ Furlough/ Layoff/ Investigation/ Mini-Hatch/ Personnel Action/ Whistleblower Appeals Hafa Adai! The Civil Service Commission requests the following information be provided to ensure proper notification of status of appealed cases. Please print the information provided below. NAME:______________________________________________________________________ Last First Middle TELEPHONE CONTACTS: _______________ __________________ _________________ PRIMARY MAILING ADDRESS: SECONDARY MAILING ADDRESS: __________________________ ______________________________ __________________________ ______________________________ __________________________ ______________________________ NAME OF ATTORNEY OR REPRESENTATIVE: ______________________________ ______________________________ DEPARTMENT/AGENCY: _____________________________ Employee will be responsible to notify the Civil Service Commission in person of any change of address or telephone contacts. Failure to notify the Commission may result in the dismissal of your case for failure to attend hearing and conferences. ____// S //________ VERNON P. PEREZ DISCLOSURE OF INFORMATION: Upon filing of any appeal, most documents submitted to the Civil Service Commission become public records or writings and may be disclosed, inspected, or copied pursuant to Freedom of Information requests, the Sunshine Law (5GCA, chapter 10) or the discretion of the Executive Director. Personal Information will not be made public. I hereby agree that upon any change of the above information I will notify the Commission Non-notification may result in my case being dismissed. Further, I have read the Disclosure of Information statement above. ________________________________________________________Signature of Employee/ Date
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