Fillable EMPLOYMENT DATA FORM MASTER

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EMPLOYMENT DATA FORM MASTER

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The EMPLOYMENT DATA FORM MASTER form is 1 page long and contains:

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  • 41 check-boxes
  • 24 other fields

Country of origin: US
File type: PDF

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Updated: HR 12/16/2016
EM
PLOYMENT DATA FORM
LEGAL
NAME:
LAST
FIRST
MIDDLE NAME
ADDRESS:
CITY:
STATE:
ZIP:
PERSONAL CONTACT
Phone Number:
PERSONAL CONTACT
Email Address:
SSN:
GENDER:
☐ F ☐ M
DIVISION/DEPARTMENT:
POSITION:
ETHNICITY:
☐
African-American Non-Hispanic
☐
Hawaiian
☐
Other Non-White
☐
American Indian/Alaskan Native
☐
Hispanic (legacy only)
☐
Pacific Islander
☐
Asian Indian
☐
Japanese
☐
Samoan
☐
Cambodian
☐
Korean
☐
South American
☐
Central American
☐
Laotian
☐
Vietnamese
☐
Chinese
☐
Mexican/Mex-American/Chicano
☐
White Non-Hispanic
☐
Filipino
☐
Other Asian
☐
Unknown
☐
Guamanian
☐
Other Hispanic
☐
Decline to state
MARITAL
STATUS:
☐ Married ☐ Divorced ☐ Separated ☐ Unmarried ☐ Widowed ☐ Decline to State
EMERGENCY CONTACT INFORMATION:
#1 EMERGENCY CONTACT NAME:
RELATIONSHIP:
PHONE NUMBER:
#2 EMERGENCY CONTACT NAME:
RELATIONSHIP:
PHONE NUMBER:
ARE YOU A VETERAN?
☐ Yes (please answer the following) ☐ No
Branch:
Date of Discharge:
Armed Service Medal Indicator:
☐
Yes
☐
No
Disabled Veteran:
☐
Yes
☐
No
☐
Active Wartime Vet
eran or Campaign Badge Veteran
☐
Protected Veteran
☐
Not a protected Veteran
ARE YOU DISABLED?
☐ Yes ☐ No
If Yes, do you need any sort of accommodation we need to be aware of? Please explain. If your
documentation is already on file with HR please state this in your explanation:
FOR HUMAN RESOURCE USE ONLY: E-Class: ______ ORG # __________ Position#_________ Start Date: ________
Received by:
Date Received:
Date Entered:
Employee Banner ID:
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EMPLOYMENT DATA FORM MASTER

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Completed 1 December 2019

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