STUDENT EMPLOYMENT PERSONNEL DATA
All information will be confidential
- -
Social Security # First Name MI Last Name Suffix
Home Street Address Local Street Address
Home City Home State Home Zip Local City Local Zip
Home Phone Local Phone Date of Birth
/ /
( ) -
-
Liberty ID# E-mail Address
Gender:
Male Female Marital Status: Single Married Name of Spouse
Race/Ethnic Ori
in: White Black His
anic Asian/Pacific Islander American Indian/Alaskan Native
I am a US Citizen: Yes No
Emergency Contact Information:
Name (Person to be contacted) Phone Number
( ) -
Street Address City State Zip
Relationship:
Spouse Mother Father Brother/Sister Grandparent Aunt/Uncle Mother-in-law
Father-in-law Guardian Friend Other - Specify ____________________
I hereby state that all of the above information is true and correct. I understand that falsifying information on
this form may result in disciplinary action, up to and including immediate dismissal.
/ /
Date
Signature
