Fillable Employee Profile Employee Profile (University of Alabama at Huntsville)

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Employee Profile Employee Profile (University of Alabama at Huntsville)

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File type: PDF

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SSN
PRE
MI SUFFIX
ZIP
BIRTHDATE HOME PHONE
Previously employed by UAH:
If yes, please indicate your employment classification(s):
Are you currently a member of the Teachers’ Retirement System of Alabama?
SEX MARITAL STATUS ETHNICITY/RACE
Are you Hispanic or Latino?
DISABILITY STATUS MEDICAL LIMITATIONS
VETERAN STATUS - SEE PAGE 2 FOR DEFINITIONS
MILITARY RESERVE STATUS
CITIZENSHIP/COUNTRY
VISA TYPE _______________
EXPIRATION DATE
______________________________
ADMISSION NUMBER ________________________________
EMERGENCY CONTACTS
PRIMARY
HIGHEST DEGREE AWARDED ________________________________________
NAME _____________________________________
DEGREE DATE(MM/DD/YY) __________________________________________
ADDRESS _________________________________
DEGREE INSTITUTION _____________________________________________
____________________________
INSTITUTION LOCATION (City/State)_________________________________
RELATIONSHIP ________________________
MAJOR __________________________________________________
TELEPHONE # 1 ____ _______ - ________
__
___
DEPENDENTS
TELEPHONE # 2
_
___
-______ - _________
__
__
SEX
SECONDARY
SPOUSE M F
NAME _________________________________
___
CHILD M F
ADDRESS______________________________
___
CHILD M F
_________________________________
CHILD M F
RELATIONSHIP _________________________
___
CHILD M F
TELEPHONE # ____ - _______ - _________ __
__
CHILD
M F
Entered: I-9 Completed:
SIGNATURE DATE Adj Srvc Dte:
Revised 06/5/2015
Employee Profile
STREET ADDRESS
CITY, STATE
LAST NAME
FIRST NAME
LIST DEPENDENT CHILDREN THAT ARE UNMARRIED, LESS THAN AGE 26.
The University of Alabama in Huntsville
CELL PHONE
COUNTY
If yes, please list the name of the employing agency: ______________________________
BANNER ID - (A#)
NON-US CITIZEN MUST ENTER INFORMATION BELOW:
NAME
DATE OF BIRTH
EDUCATION
_____________________
SEPARATION DATE:
EMAIL ADDRESS
Yes
No
FACULTY
STAFF
STUDENT
OTHER PERSONNEL
PT/LECTURER
GTA/GRA
MALE
FEMALE
MARRIED
SINGLE
DIVORCED
SEPARATED
WIDOWED
WHITE
BLACK OR AFRICAN AMERICAN
NONE
WHEELCHAIR
SEMI-AMBULATORY
SIGHT
HEARING
SPEECH
LEARNING
MENTAL/PSYCHOLOGICAL
COORDINATION
OTHER__________________________________
NONE
BLIND
CARDIOPULMONARY STRESS
DIABETIC
EPILEPTIC
HEARING IMPAIRED
HEART CONDITION
PARAPLEGIC
PROSTHETIC LIMB
QUADRIPLEGIC
NO HEAVY LIFTING
NO CHEMICAL INHALATION
OTHER____________________________
OTHER PROTECTED VETERAN ONLY
VIETNAM VETERAN ONLY
BOTH VIETNAM AND OTHER ELIGIBLE VETERAN
SPECIAL DISABLED
NOT IN RESERVE
ACTIVE RESERVE
INACTIVE RESERVE
INACTIVE RESERVE SUBJECT TO CALL UP
USA
OTHER ___________________
YES
NO
ASIAN
AMERICAN INDIAN OR ALASKA NATIVE
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
NO
YES
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Veteran of the Vietnam-era means a person who (i) served on active duty in the U.S. military, ground, naval or air service
for a period of more than 180 days, and who was discharged or released therefrom with other than a dishonorable
discharge, if any part of such active duty was performed (A) in the Republic of Vietnam between February 28, 1961 and
May 7, 1975, or (B) between August 5, 1964 and May 7, 1975, in all other cased, or (ii) was discharged or released from
active duty in the U.S. military, ground, naval or air service for a service-connected disability if any part of such active duty
was performed (A) in the Republic of Vietnam between February 28, 1961 and May 7, 1975, or (B) between August 5,
1964 and May 7, 1975, in any other location.
Special Disabled Veterans means (i) a veteran of the U.S. military, ground, naval or air service who is entitled to
compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws
administered by the Department of Veterans’ Affairs for a disability (A) rated at 30 percent or more, or (B) rated at 10 or
20 percent in the case of a veteran who has been determined under Section 38 U.S.C. 3106 to have a serious
employment handicap or (ii) a person who was discharged or released from active duty because of a service-connected
disability.
Newly Separated Veterans means any veteran who served on active duty in the U.S. military, ground, naval or air service
during the one year period beginning on the date of such veteran’s discharge or release from active duty.
Other Protected Veterans means veterans who served on active duty in the U.S. military, ground, naval or air service
during a war or in a campaign or expedition for which a campaign badge has been authorized. For those with internet
access, the information required to make this determination is available at
http://www.opm.gov/veterans/html/vgmedal2.asp.
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Employee Profile Employee Profile (University of Alabama at Huntsville)

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Completed 28 August 2020

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