PERSONNEL DATA SHEET

  • IMPORTANT: Your name must appear on this form EXACTLY as shown on your social security card.
  • An original signed social security card must be presented with this form.

Employment Status: / Expected Start Date: / Supervisor:
New Hire Rehire / / / / Supervisor Email:

Personal Information (Enter name exactly as it appears on your Social Security card):

Social Security Number/ / / Prefix Dr. Miss Mrs. Mr. Ms.
FirstName / Middle Name / Last Name / Suffix
II. Ill. IV. Jr. Sr.
Mailing Address / Street or P.O. Box Number / Apt/Lot # / City / State / Zip Code
Home Phone / Cell Phone / Current Email

Biographic Information:

Date of Birth / Gender Male Female / Marital Status Divorced Married Separated Single Widowed
Are you a U.S. Citizen? / If no, country of origin / Visa Type / Visa Number
Yes No
Are you Hispanic / Latino?
Yes
No (If no, select primary race from the boxes at the right) / What is your primary race? / White / Black/African American / Native Hawaiian/Pacific Islander
Asian / American Indian/Alaskan Native
Please check any additional races that apply / White / Black/African American / Native Hawaiian/Pacific Islander
Asian / American Indian/Alaskan Native
Are you a veteran?* / If yes, please check and complete all that apply / Other Protected Veteran / Armed Forces Service Medal Veteran
Recently Separated Veteran
Other / Veteran File Number:
Active Duty Separation Date:
Yes No / Vietnam-Era
Special Disabled Veteran

Emergency Contact Information:

Relationship
Child Friend Grandparent Guardian Sibling Parent Relative Spouse Partner Neighbor
FirstName / Middle Name / Last Name
Mailing Address / Street or P.O. Box Number / Apt/Lot # / City / State / Zip Code
Home Phone / Cell Phone / Current Email

Educational Information:

Indicate Highest Education Level Completed / High School Graduate / GED / Associate Degree / Indicate any addition to high school or Bachelor’s degree / Some College
Bachelor’s degree / Master’s degree / Doctorate degree / Some Graduate
University or College Granting Highest Degree
City and State of University / DATE Highest Degree Awarded / /
Major Field of Study / Is your highest degree considered terminal? Yes No

Previous UALR/ArkansasStateAgency Employment Information:

Have you ever worked full-time for UALR or any Arkansas State Agency? Yes No / When / Where
When / Where
When / Where
Signature / Date