HR Rev 11/2019
Employee Personal Data Form
Please Select One: New Employee Rehire Update Employee Data
Effective Date:
Personal Information
(Last, First, MI):
Dependent Information
Demographic Information
Ethnicity: Please check the box that best describes your ethnicity
Asian/Pacific Islander American Indian/Alaskan Native Black/African American Hispanic White
Other: ________________________________________________________________
Military/Veteran Status: Please select all that apply
Are you a disabled Veteran? Yes No Do you have current or prior military service? Yes No
Vietnam and Other Eligible Veteran
Citizenship: Please select all that apply
Are you a US Citizen?
No If No please select one:
Emergency Contact Information
Please return completed form to Human Resources. HR/Payroll use only below this line.
Job Position:
1.Record created/updated in QSS: By: ________ Payroll #:_______________
(forward offer letter, W-4, de4, Direct Deposit, Retirement Information to Payroll)
2.Record created/updated i
n TC+: By:________ 3. Record created/updated in Banner: By: ________ A#_____________________