Employee:___________________________________ Date:______________________
MOTLOW STATE COMMUNITY COLLEGE
DATA ENTRY INFORMATION FORM
DEMOGRAPHIC INFORMATION: (PPAIDEN)
Last Name First Name Middle
(List name exactly as it appears on Social Security Card)
Nickname/Name preferred Salutation Mr. Mrs. Dr.
Position Title:
Appt/Appt Change Date Salary/Salary Change Amt.
Gender F M Date of Birth SSN
Mailing Address
County of Primary Residence
Citizenship N-Non Resident Alien P-Perm Res. Alien, Asylee, Refugee
R-Resident Alien (tax purposes) T-Reclassification in Progress Y-U.S. Citizen
Marital Status D–Divorced M-Married N-Domestic Partner P-Separated S-Single W-Widowed
RACE/ETHNICITY:
1. Do you consider yourself to be Hispanic, Latino or of Spanish Origin?* Yes - 50 No
*The term “Hispanic or Latino or Spanish Origin” is defined as a person of Cuban, Mexican, Puerto Rican, South or Central
American, or other Spanish culture or origin, regardless of race.
2. In addition, select one or more of the following racial categories to describe yourself:
Alaska Native - 10 Black or African American - 40
American Indian - 20 Asian - 30
Native Hawaiian/Other Pacific Islander - 30 White - 60
Racial Category Definitions:
White - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa
Asian - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent
including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
Black or African American - A person having origins in any of the Black racial groups of Africa
Native Hawaiian or Other Pacific Islander - A person having origins in any of the original peoples of Hawaii, Guam,
Samoa, or other Pacific Islands
American Indian or Alaska Native - A person having origins in any of the original peoples of North and South America
(including Central America), and who maintains a tribal affiliation or community attachment
VETERAN STATUS: None:
Special Disabled Armed Forces Service Medal Veteran Vietnam Veteran Only
Recently Separated Other Protected Veteran Both Vietnam and Other Eligible Veteran
Active Duty Separation Date:
EDUCATION: (PEAFACT)
Degree Required for Position: Completion Date:
Granting Institution:
Highest Degree: Completion Date:
Granting Institution:
We request your voluntary completion of this information to be used ONLY for the purpose of monitoring the success of our
Affirmative Action Plan.
