Fillable Western Connecticut State University Adjunct Faculty Member New (Western Connecticut State University)

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Western Connecticut State University Adjunct Faculty Member New (Western Connecticut State University)

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Revised 2/13
Western Connecticut State University
Adjunct Faculty Member
New Hire Data Sheet
____________________ /____________________ /______
Last Name First Name M.I.
Social Security #:
_ _ _ - _ _ - _ _ _ _
Prefix:
Dr. Mr. Miss Ms. Mrs.
Suffix:
Jr. Sr. Other:
Date of Birth:
______ /______ /______
Month Day Year
Disabled Not Disabled
Have you ever worked for the State of Connecticut before?
Yes No
If so, where?
Are you interested in having your paycheck on direct
deposit? Yes No
If Yes, please request a Direct Deposit Form
from Human Resources.
American Indian/Alaskan Native Asian/Pacific Islander
Black Hispanic White Not Applicable
* In compliance with federal and state regulations, Western Connecticut State University is required to collect and maintain data
on the race, sex, and ethnicity identity of all employees. Your responses are strictly voluntary and will help in implementing
Western’s Affirmative Action program.
Male Female
Married Separated Divorced Single Widowed Civil Union
City: State: Zip Code:
Mailing Phone #: ( )
Please sign below acknowledging receipt of the above items and that all of the information given above is
correct to the best of your knowledge.
___________________________________________ _____________________________
Employee’s Signature Date
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Western Connecticut State University Adjunct Faculty Member New (Western Connecticut State University)

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Completed 2 February 2021

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