HUMAN RESOURCES PERSONAL INFORMATION FORM–FACULTY/STAFF

THIS FORM MUST BE COMPLETED ON A COMPUTER

Date: 1/7/2013

Required Personal Email address:

*Use the spacebar or click to “check” boxes throughout the form*

Please check New Hire Rehire Making a Change ofAddress Name Change

The information provided on this form is used for University benefits, tax information, service awards, mail, telephone directory, and for all University and government reporting. It is essential that all elements be accurate and truthful. Your name printed on this form and tax forms must match the legal name printed on your social security card.

Human Resources may request to view your social security card or legal name change document to verify that your name is correctly recorded in the system.

PLEASE PRINT YOUR INFORMATION

Social Security Number:-- Department:

Name:

(First, Middle, Last, Suffix if needed) Use Legal Name

Preferred first name:Maiden Name:

ROMAN CATHOLIC RELIGIOUS AFFILIATION(If applicable)

R1- Society of Jesus

R2- Other Religious Order

R3-Priest (diocesan)

ADDRESS INFORMATION MUST BE EITHER – HOUSE OR APT.

Permanent Address:

(NO CAMPUS ADDRESSES – NO BUSCH CENTER MSC #’S)

City and State:

Zip Code:

Permanent Telephone:

PERSONAL INFORMATION (Please Check Selection)

Marital Status:MarriedSingle Divorced Separated

Widowed Religious Order Life Partnered

Birth Date://

Gender: Female Male

Citizenship: Non- Citizen If no, country of origin: Passport Expiration:

Visa Type: Visa Expiration Date:

Citizen

Non- Citizen Permanent Resident

VOLUNTARY DEMOGRAPHIC DATA(Release of demographic information is voluntary). The information obtained will be kept confidential and may only be used in accordance with provisions of applicable laws.

Ethnicity: Are you Hispanic or Latino? (check only one) Yes No Not Disclosed

Race: Review each of the following categories and check the box that identifies your race/national origin (you may select more than one category).

White (not Hispanic or Latino)

Black or African American (not Hispanic or Latino)

Native Hawaiian or other Pacific Islander (not Hispanic or Latino)

Asian (not Hispanic or Latino)

American Indian or Alaska Native (not Hispanic or Latino)

Not Disclosed

Disability: Are you an individual with a disability? Yes No Not Disclosed

If you selected “Yes”, please describe:

If you think you may need accommodations, please contact Human Resources for assistance.

Veteran Status: Review each of the following categories and check the box that identifies your veteran status (you may select more than one category).

Non-Veteran

Disabled Vietnam

Special Disabled Veteran

Armed Forces Service Medal Veteran (If you selected “Armed Forces Service Medal Veteran”, please provide the name of the Expedition or Campaign: )

Vietnam-Era Veteran

Recently Separated Veteran (If you selected Recently Separated Veteran, please provide your date of separation: MM/DD/YY: //)

Other Protected Veteran

Not Disclosed

Military Status: Active Reserve Inactive Reserve

Active National Guard Inactive Nat. Guard-subject

to call up

Inactive National Guard Not in Active Reserve

Does Not Apply to ME

EMERGENCY CONTACT

Name:

Relationship:

Home: / Work:
Cellular: / Other:

Telephone:

EDUCATIONAL BACKGROUND (please list Undergrad, Graduate, and/or Professional, and Post Graduate in Order)

School Date Degree For Office Graduated Use Only

/
/

Undergrad

/
/

Graduate

/

Post Grad.

Date://

Specialty:

Date: //

Board Certified:

NAME OF SPOUSE OR CHILDREN

(This information is needed for benefits administration)

Name Birth Date Social SecurityRelationship Number

// / --
// / --
// / --
// / --

I certify that the information provided in this form is correct.

Signature______Date______

Saint Louis University is an Equal Opportunity Affirmative Action Employer.