Fillable Employee-Data-Form-online ____ New employee ____ Updated employee data

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Employee-Data-Form-online ____ New employee ____ Updated employee data

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Country of origin: US
File type: PDF

U.S.A. forms for Clarion University of Pennsylvania

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____ New employee ____ Updated employee data
Clarion University of Pennsylvania
Employee Data Form
(please print or type)
Full Name: _____________________________________________________________________________
Last First Middle
Date of Birth: __________________________
Home Address: _________________________________________________________________________
Street or Box Number
_____________________________________________ _________________ _________________ ___________________________________
City State Zip Code County
School District for Above Address: _________________________________________________________
Municipality for Above Address: ___________________________________________________________
____ Township _____ Borough _____ City
Home Phone: _______ - ____________________
Other Phone: _______ - ____________________ (other phone will not be published)
If other phone provided please indicate if cell phone: _____ Yes _____ No
Gender: _____ Male _____ Female
EEOC Data: _____ Black (not of Hispanic origin) _____ Hispanic
_____ White (not of Hispanic Origin) _____ American Indian
_____ Asian
Marital Status: ____ Single ____ Married ____ Widowed ____ Divorced ____ Separated
____ Life Partner
Are you a U.S. Citizen? _____ Yes _____ No
If no, classification of VISA: _____________________________________________________________
Position at Clarion University: ____________________________________________________________
Campus Department: ___________________________________________________________________
Campus Address: ______________________________________________________________________
Campus Phone: _______________________________________________________________________
Were you ever employed with the Commonwealth in any other capacity prior to this date? ____Yes ____ No
If Yes, list where employed and dates of service:
________________________________________________ ___________________________
________________________________________________ ___________________________
Have you ever been a member of any retirement system? _____ Yes _____ No
If Yes, please check system. Public School Retirement System ________
PA State Employees Retirement System ________
TIAA-Teacher Ins. & Annuity Assoc. ________
**Please continue on other side**
Print Form
Submit by Email
DEGREE INFORMATION
Last Degree Earned: ___________________________________ Date Earned: __________________
University: ________________________________________________________________________
EMERGENCY CONTACT DATA
NAME: _________________________________________ Relationship: ______________________
ADDRESS: _______________________________________________________________________
CITY, STATE, ZIP: ________________________________________________________________
TELEPHONE: _____________________________ OTHER PHONE: _______________________
Where would you like your payroll check directed: Department ___________
B-25 Carrier ___________
Mailed ___________
Do you wish to have your home phone number and home address listed in the campus directory? ____ Yes ____ No
_______________________________________________ ___________________
Employee Signature Date
*******Office of Human Resources use only****************
Campus Address:_______________________________________________________________________________
Campus Phone:______________________________________
Work Schedule:______________________________________
10/03/05
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Employee-Data-Form-online ____ New employee ____ Updated employee data

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Completed 16 November 2019

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