ࡱ> 685 bjbj )"̟̟ h$$8q!/////!!!!!!!i" %v!Z^! //++!   ^//! !  D h @o*l  <A!0q! % %   $ :   ID/SSN ( New Hire ( Rehire ( Change-other ___________________ Effective Date ___________________ Name _____________________________________________ Previous Name ________________________ Last First MI (if applicable) Date of Birth _______________________________ Preferred First Name __________________  The following race, ethnic and gender information is used for EEO statistical purposes and general reporting only Do you consider yourself to be Hispanic/Latino? Yes Sex: No ( Male In addition, select one or more of the following racial categories to declare yourself: ( Female American Indian or Alaska Native Asian Black or African American Native Hawaiian or Pacific Islander White The Department of Labor has asked employers to report Veteran status of our employees. The regulations provide that this information be voluntarily obtained from employees. Please check all categories that you qualify for: Duty Separation Date is _________________________ ( Veteran of the Vietnam Era ( Other (eligible) Veteran ( Both Vietnam/Other Protected Veteran ( Special Disabled Veteran  Mailing Address: Street __________________________________ Home Telephone: ( _____ ) ________________ __________________________________ Campus Address: _________________________________ Campus Building Room __________________________________ Campus Telephone: ______________________ City State Zip Confidential ( Yes ( No (If you indicate NO, you are authorizing disclosure of your address and telephone number to any member of the public upon request. ( If you indicate YES you are voluntarily submitting your address and telephone number in confidence and believe that release of this information to members of the public would be an unreasonable invasion of your personal privacy and/or safety. By indicating YES, you may miss some mail or call you would have wished to receive.  Emergency Contact Information: Primary - (local if possible) Relationship ________________________ Secondary optional Relationship ______________________ Name __________________________________________ Name __________________________________________ Address ________________________________________ Address ________________________________________ ________________________________________ ________________________________________ City State Zip City State Zip Telephone ( _______ ) __________________ Telephone ( _______ ) __________________ Employee Signature __________________________________________________________ Date ________________ Send to HRIS, Downtown Center 321 Questions? 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