Employee Signature:

 

    Date:

(Handwritten Please)

Please return all copies of completed form to Human Resources.

Office of Human Resources Form

Employee Information

Staff / Faculty / Student / Other - Non Employee

New Employee Information

Employee Signature:

 

    Date:

(Handwritten Please)

Please return all copies of completed form to Human Resources.

Office of Human Resources Form

Employee Information

Staff / Faculty / Student / Other - Non Employee

Select one:   New Employee    Rehired Employee    Current Employee Update/Change*
SSN (e.g. 000000000):       Employee ID Number: 
Org Unit (Dept):    * Some changes require supporting documentation.

Personal Data: Please complete applicable fields.

Title (Mr., Ms. Dr., etc):

Legal Last Name:

First Name:

Middle Name:

  Nickname:

Preferred Last Name:

Suffix (Jr. Sr., II, etc.):

Birth Date:

Gender:

Highest Ed. Level:

Marital Status:

 Ethnicity:

 

Military Status:

Active

 On Call

(Hispanic/Latino  or  Not Hispanic/Latino)

   (You may select one.) Reserve Retired

Ethnic Origin:

(You may select one or more below.)

     Inactive Reserve Discharged

   American Indian or Alaskan Native

  

 

 Inactive Not Applicable

   Asian

   Veteran Status: Vietnam Era Veteran

   Black or African American

     Newly Separated Veteran (3 years)

   Native Hawaiian or other Pacific Islander

  

 If veteran status,

 Armed Forces Service Medal Veteran

   White

  

 Discharge Date:

 Special Disabled Veteran 

 

  

Disabled Veteran

Providing this information is voluntary.

    Other Protected Veteran
        Non-Veteran

 

Permanent Address

Phone Numbers

Street Address 1:   Home:  
Street Address 2:   Cell:  

City/County:

   Work:  

State/Zip Code:

   Fax:  

Country:

   Pager:  
      Other:  
Mailing Address  (if different from Permanent Address)    
Street Address 1:

 

E-mail:

Street Address 2:      

City/County:

 

  

Preferred Method of Contact:

State/Zip Code:

   

 

Country:

 

 

 (E-mail, Home Phone, etc.)

 Last Name: Employee ID (if known): 
   

Family Member/Dependents:   Number of

                                               Dependents:  

For more than eight eligible dependents, please attach list to form.

       

Last Name

First Name

Relationship

DOB 

 

 

 

 

 

 

 

 

   

Spouse, Child, Extended Family Member*, Child of Ext Fam Member*

  
* Refer to Benefits policies for potential eligibility.  

Emergency Contacts

         
  Primary Emergency Contact      

Last Name:

   

 

First Name:

   

 

Area Code/Number:

      
         
     
         
  Secondary Emergency Contact      

Last Name:

      
First Name:      

Area Code/Number: