University of North Carolina at Charlotte

Personnel Profile for PERMANENT FACULTY OR STAFF

The information requested on this form will be used for the following purposes:  To establish an employee record on the University’s Human Resources System (which includes Payroll)  Compliance with Equal Employment Opportunity and Affirmative Action reporting requirement provisions of State and Federal laws  Compliance with State law regarding Military Selective Service

Name Casual Name (ex. Bob, Kathy, etc.) Last 4 digits of SSN

Department / Office Department Phone Number

Please complete all requested information and indicate any of the following fields you would like omitted from the Campus Directory by placing a check in the box preceding the specific field(s). (Note: Social Security Numbers are not published) Omit? Street Address City State Zip Code County

Omit? Home Telephone Number Omit? Spouse Name

The University is required to notify the Retirement System immediately when a retired member who is in receipt of a monthly retirement benefit from the Teachers’ and State Employees’ Retirement System (TSERS) of North Carolina is hired by the institution.

Are you retired from the TSERS of North Carolina and in receipt of a monthly retirement Do you have prior service with the State of North Carolina? benefit? Yes No Yes No

Education Please indicate your highest level of education obtained by placing an ‘X’ in the box left of your choice

Less than 9th Grade Less than High School High School or GED High School + 1 yr college High School + 2 yrs college High School + 3 yrs college Bachelors Degree Masters Degree Doctorate Professional Degree (Law, Medical, etc.) If you hold one or more college degrees, please provide information regarding the highest educational degree held: Year Major or Degree Institution Awarded Field Name

Demographic Information: Are you Hispanic or Latino? Yes No Not Disclosed Optional Race Category (Select One or More): If you have identified yourself as Hispanic or Latino, you are not required to select and additional category. B - Black I - American Indian or Alaskan Native W - White

P – Native Hawaiian / Pacific Islander A - Asian Two or More Date of Birth Gender Month Day Year Male Female Country of Permanent Residence Visa Type (if applicable) Expiration Date (if applicable)

Disposition of Information Portions of this information will be entered into the Human Resources (HRS) data base, after which disposition of the form is as follows:

For SPA employees, the form is filed in the Personnel Folder maintained in the Human Resources Department. For EPA employees, the form is filed in the Personnel Folder maintained in the Office of the Academic Affairs – Personnel and Budget.

Employee Signature Date

For Human Resources Use Only

Rev 10/2009 Page 1 of 3 PERMANENT EMPLOYEE Personnel Profile Information Form Faculty EPA Staff SPA Staff LEO Hire Date:

Rev 10/2009 Page 2 of 3 PERMANENT EMPLOYEE Personnel Profile Information Form Veteran Status (Check all that apply) Armed Forces Service Medal Veteran means any veteran who while serving on active duty in the U.S. military, ground, naval, or air service, participated in a United States Military Are you an Armed Forces Yes No operation to which an Armed Forces service medal was awarded pursuant to Executive Service Medal Veteran? Order 12985 (61 FR 1209) www.opm.gov/veterans/html/vgmedal2.asp. Recently Separated Veteran means any veteran during the three year period beginning on Date of Discharge: the date of such veteran’s discharge or release from active duty in the U.S. military, Yes No / /20__ ground, naval or air service. “Veteran of the Vietnam era” means a person who (1) served on active duty for a period of more than 180 days and was discharged or released with other than a dishonorable discharge, if any part of such active duty occurred: (A) in the Republic of Vietnam between Are you a Veteran of the Yes No 2/28/61 and 5/7/75; or (B) between 8/5/64 and 5/7/75, in all other cases or (2) was Vietnam Era? discharged or released from active duty for a service-connected disability if any part of such active duty was performed as described above. “Special disabled veteran” means a veteran who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Veterans Administration for a disability rated at 30 percent or more, or Are you a special disabled Yes No rated at 10 to 20 percent in the case of a veteran who has been determined to have a veteran? serious employment disability; or a person who was discharged from active duty because of service connected disability. Disabled Veteran means (1) a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs, or Are you a disabled veteran? Yes No (2) a person who was discharged or released from active duty because of a service connected disability. Other Protected Veteran means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war on in a campaign or expedition for which a Are you another protected Yes No campaign badge has been authorized, under the laws administered by the Department of veteran? Defense (www.opm.gov/veterans/html/vgmedal2.asp.) Disabling Condition A disabling condition is any impairment that substantially limits one or more major life activities. A disabled person is one who has such impairment. The reporting of a disabling condition is voluntary. A. Non/Prefer not to report H. Nervous system/Neurological disorder

B. Blind or severely visually impaired I. Mentally disturbed

C. Deaf or severely hearing impaired J. Mental retardation

D. Loss or limited use of arms and/or Hands K. Learning disability

E. Non-ambulatory (must use wheelchair) L. Heart disease F. Other orthopedic impairment (including amputation, arthritis, back injury, M. Diabetes cerebral palsy, spina bifida, etc.) G. Respiratory impairment N. Speech impairment

X. Other (Please specify ) Military Selective Service Compliance In accordance with General Statute 143-421.1, I hereby certify, as a condition of employment, that I have complied with the requirements of the Military Selective Service Act. My specific compliance is as follows:

I certify that I am registered with the Selective Service.

I am female I am in the armed services on active duty. (Members of the Reserves and Nation Guard are not I certify that I am not required to be considered on active duty.) registered with the Selective Service because: I am currently 26 years of age, or older.

(Please ‘X’ one of the following reasons) I am a permanent resident of the Trust Territory of the Pacific Island or the Northern Marina Islands. I am a non-immigrant alien. Signature of a member of the Human Resources Department: Date:

Rev 10/2009 Page 3 of 3 PERMANENT EMPLOYEE Personnel Profile Information Form Emergency Notification Information This information will be used to make an appropriate notification in the event of an emergency involving a faculty or staff member.

Employee Name Last 4 digits of SSN UNC Charlotte ID

Department or Office Name Department Phone Number

PERSON # 1 TO CONTACT IN THE EVENT OF AN EMERGENCY A – Aunt / Uncle F – Father P – Parents Employee’s B – Sibling G – Grandparents R – Grandchild Relationship to C – Child / Children M – Mother S – Spouse named contact D – Domestic Partner N – Friend / Neighbor U – Guardian E - Embassy O - Other V – Advisor / Sponsor LAST Name FIRST Name Middle Initial

Address Lines 1 & 2 City State Zip Code

Contact Telephone Numbers

Home Business Mobile

PERSON # 2 TO CONTACT IN THE EVENT OF AN EMERGENCY A – Aunt / Uncle F – Father P – Parents Employee’s B – Sibling G – Grandparents R – Grandchild Relationship to C – Child / Children M – Mother S – Spouse named contact D – Domestic Partner N – Friend / Neighbor U – Guardian E - Embassy O - Other V – Advisor / Sponsor LAST Name FIRST Name Middle Initial

Address Lines 1 & 2 City State Zip Code

Contact Telephone Numbers

Home Business Mobile

Rev 10/2009 Page 4 of 3 PERMANENT EMPLOYEE Personnel Profile Information Form