FORM: HR-PI / REV. JAN 2013 / P:\SHARE\WIKI FORMS\WIKI FORMS - WORD DOC'S\PERSONNEL SYSTEM INFORMATION FORM.HR-
PI.docx
San Bernardino Community College District
Personnel System Information Form
Site: SBVC CHC DIST Department: ______________________ ______
Full Name: _________________________________, _________________________ _____________________
LAST FIRST MIDDLE
Male
Other Names Used: ____________________________ Date of Birth: _________________ Female
Home Address: Mailing Address (if different):
_________________________________________ _________________________________________
_________________________________________ _________________________________________
Home Phone: ( ) _____________________ Mobile Phone: ( ) _____________________
Are you currently working for another school district? Yes No
If yes, which District: ________________________________________________________________________
Disabled: Yes No
Do you require a reasonable accommodation to perform the essential functions of your job? Yes No
If yes, please specify: ________________________________________________________________________
__________________________________________________________________________________________
Veteran: Yes No Disabled Veteran: Yes No Vietnam Veteran: Yes No
Ethnicity: Are you Hispanic: Yes No
If Yes, Indicate Hispanic or Latino Race: Mexican, Mexican-American, Chicano
Central American
South American
Hispanic / Other
Race:
American Indian/Alaskan
Asian, Cambodian
Asian, Chinese
Asian, Hmong
Asian, Indian
Asian, Japanese
Asian, Korean
Asian, Laotian
Asian, Other
Asian, Vietnamese
Black
Filipino
Other Non-White
Pacific Islander, Guamanian
Pacific Islander, Hawaiian
Pacific Islander, Other
Pacific Islander, Samoan
White
Signature: _______________________________________________ Date: ______________
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