Employee Signature:

    Date:

(Hand Written Please)

Please Return All Copies of Completed Form to Human Resources

 SSN (e.g. 000000000):

 Employee ID:

Org Unit (Dept):

 I am a past employee of NKU

Personal Data: Please Complete Applicable Fields

Title:

Mr. Mrs. Miss Ms. Br. Dean Dr. Fr. Pres. Prof. Rabbi Rev. Sr. VP Other

Legal Last Name:

First Name:

Middle Name:

  Nickname:

Preferred Last Name:

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

CPA Ed.D Esquire M.D. Ph.D RN Other

Birth Date:

Gender:

Female Male TBD

Highest Ed. Level:

Business Sch Cert. 1 Yr College Work 2 Yrs College Work Associate Degree 3 Yrs College Work 4 Yrs College Work Bachelor's Degree Master's Prog. Work Master's Degree Doctoral Prog. Work PHD Laws/JD MD

Marital Status:

Single Married Widow Divorced Seperated Unknown

Additional Personal Data:  Please Complete Applicable Fields

 Ethnic Origin:

White Black Hispanic Asian or Pacific Islander American Indian/Alaskan Native Hawaiian Hispanic White Only Hispanic All Other Unspecified

Military Status:

Inactive Active Retired Inactive reserve Reserve On call Non-Vets 100 Veteran

Ethnicity:

Hispanic/Latino Not Hispanic/Latino

Veteran Status:

Special disabled veteran Vietnam-era veteran Other veteran Newly seperated veteran Non-veteran

If No, List Visa Status:

   Perm. Res. Country:

Addresses:  Please Complete Applicable Fields

Address Type:

Permanent Residence Mailing Address

Address Type:

Permanent Residence Mailing Address

Address:

Address:

City/County:

City/County:

State/Zip Code

   State/Zip Code:

Country:

Country:

Area Code/Phone:

Home Cell Work Fax Page Other

 E-mail:

Area Code/Phone:

Home Cell Work Fax Page Other

Preferred Contact:

Work Phone Home Phone Cell Phone Fax E-mail

Family Member/Dependents: No. Dependents:  

For more than Four Eligible Dependents, Please Attach List to Form.

Last Name

First Name

Relationship

DOB 

  Child Foster Child Legal Dependent Spouse

  Child Foster Child Legal Dependent Spouse

  Child Foster Child Legal Dependent Spouse

  Child Foster Child Legal Dependent Spouse

Please Provide Emergency Contact Information 

Last Name:

Last Name:

First Name:

First Name:

Area Code/Phone:

Home Cell Work Fax Page Other

Area Code/Phone:

Home Cell Work Fax Page Other