Date of Employment _____________ Employee Category _____________
Employee Class _________________ ORGN Code ___________________
IPEDS Primary Function _________
Northeast Mississippi Community College
This form must be completed by all persons receiving payroll checks. For any revisions to the
information originally submitted, employee may fill in name and the information that should be changed.
NAME ____________________________________________________________________
Last First Middle
(List full legal name as it appears on Social Security records.)
Social Security Number ___________________________________
Address (permanent mailing address) ____________________________________________
City __________________________ ______ State ___________ Zip Code _____________
Telephone Number __________________________County __________________________
Date of Birth: Day ________ Month ____________ Year __________
Martial Status ______________________________ Male ________ Female _________
Are you Spanish/Hispanic/Latino? Yes ________ No _________
What is your race? Mark one or more races to indicate what you consider yourself to be.
_______ White ______ Asian
_______ Black or African American ______ Native Hawaiian or Other
_______ American Indian or Alaskan Native Pacific Islander
Driver’s License Number ______________________________ Exp. Date _______
If not Mississippi Driver’s License, list state ________________________________
Are you an active member of the Mississippi Public Employees’ Retirement System (PERS)?
_________ YES _________ NO
If yes, list name of employer ___________________________________________________
Contact Person (In Case of Emergency)
NAME __________________________________________________________________
Relationship ______________________________________________________________
Address __________________________________________________________________
Telephone Number _________________________________________________________
(Work) (Home) (Cell)
Effective: July 1, 2013