January 2016
This form has been designed for Human Resource/Compensation Management System (HR/CMS) and may
change due to further process developments and upgrades.
PERSONAL DATA FORM
This form is MANDATORY for Payroll Processing
PLEASE PRINT OR TYPE CLEARLY
LAST NAME:
FIRST NAME:
MI:
MARITAL
STATUS:
SINGLE MARRIED
DIVORCED WIDOWED
SMOKER? YES
NO
HOME ADDRESS:
ADDRESS 1:
MAILING ADDRESS (IF DIFFERENT):
ADDRESS 2:
ADDRESS 2:
CITY:
STATE:
ZIP:
CITY:
STATE:
ZIP:
TELEPHONE # :
and EMAIL ADDRESS:
GENDER: FEMALE MALE Current student at NSCC? (at least 6 credits per semester) YES NO
HIGHEST EDUCATION
LEVEL:
Less than H.S. H.S. Graduate Technical School Some College
2-Yr College Bachelors Some Graduate Masters
Doctorate MD, DDS, JD Post Doctorate
BIRTHDATE:
SOCIAL SECURITY NO. :
ETHNICITY:
Hispanic or Latino
Not Hispanic or Latino
RACE:
(Check all
that apply)
American Indian or Alaska Native Asian
Black or African American Native Hawaiian or Other Pacific Islander
White Two or More Races, specify____________________________
MILITARY
STATUS:
No Military Service Active Reserve Inactive Reserve Retired Military
Vietnam Era Veteran Vietnam Veteran Other Eligible US Veteran
Emergency Contact Information:
CONTACT NAME:
RELATIONSHIP:
ADDRESS:
DAYTIME PHONE:
Other Information (Please Complete):
HAVE YOU EVER HELD ANOTHER FULL-TIME POSITION FOR NSCC OR THE COMMONWEALTH? YES NO
IF YES, WHERE?
DATES EMPLOYED:
UNDER WHAT NAME:
S
IGNATURE: _______________________________________________ DATE: _________________________________
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