HR Rev 11/2019
Employee Personal Data Form
Please Select One: New Employee Rehire Update Employee Data
Effective Date:
Personal Information
Name
(Last, First, MI):
Preferred Name:
Street Address:
City:
State:
Zip:
Home Phone:
Mobile Phone:
Email Address:
Social Security Number:
Gender:
Male
Female
Marital Status:
Single
Married
Divorced
Widowed
Dependent Information
Name
Relationship
Date of Birth
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 Veteran Only
Vietnam and Other Eligible Veteran
Other Protected Veteran
Citizenship: Please select all that apply
Are you a US Citizen?
Yes
No If No please select one:
Permanent Resident
Non-Resident Alien
Emergency Contact Information
Primary Contact Name:
Phone Number :
Relationship:
Secondary Contact Name:
Phone Number :
Relationship:
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#_____________________
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