Office of Human Resources

OFFICE OF HUMAN RESOURCES 300 College Park Dayton, Ohio 45469-1614

CONFIDENTIAL EMPLOYEE DATA RECORD Full Time Part Time

(Please type or print in black ink and attach a current resume.) SECTION I – Please use legal name as it appears on your social security card.

Name S.S.# University ID Last First MI Nickname or Preferred Name: Former Last (not to be used on legal documents) Name(s): Home Address PO Box Street City County State Zip

Ohio School District Name School District #

Home Telephone Number Listed Unlisted Mobile Telephone Number

Date of Birth Place of Birth (city/state) Gender Male Female SECTION II

Race: Are you Hispanic or Latino? (A person of Cuban, Mexican, Puerto Rican, South or Central Yes No American, or other Spanish culture or origin) Please identify your race by selecting one or more of the following: American Indian or (A person having origins in any of the original peoples of North and South America (including Alaskan Native Central America), and who maintains a tribal affiliation or community attachment) Black or African (A person having origins in any of the black racial groups of Africa) American Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, Philippine Islands, Thailand, and Vietnam) Native Hawaiian or (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Other Pacific Islander Pacific islands) White (A person having origins in any of the original peoples of Europe, the Middle East or North Africa) Are you a US Citizen? Birth Derivative Naturalization Derivative: Naturalization: Date Date Certificate No. Petition No. Place Place If not a US Citizen: Are you authorized to work in the Yes Do you intend to remain in Yes Country of US? No the US permanently? No Citizenship: Have you applied for permanent Yes Date Country of Birth:

residency? No Applied: Country of Residence: PROOF OF CITIZENSHIP OR IMMIGRATION STATUS IS REQUIRED FOR EMPLOYMENT Type of Visa: Issue Date: Expiration Date: Visa Primary Purpose (as listed on I-20, DS-2019, or I-94) Arrival Date in US: If Alien: Registration No. Date Port of Entry

Marital Status: Single Married Divorced Widow/Widower Religion: Catholic Protestant Other No Preference Vocation: Lay Person SM Brother SM Priest SM Sister Other Priest Other Sister Other Religious Degree Information:

Degree Discipline Date Awarded Institution/Location

Certification (s) Renewal Date: or Licensure

In case of emergency:

Name Relationship

Address Street City State Zip

Telephone Numbers: Home: Work: Mobile:

Spouse’s Name (if not listed above)

Telephone Numbers: Home: Work: Mobile:

Spouse – UD Employee? Yes No Department

Date of Hire Department Job Title

Supervisor’s Name Building Room No.

Campus Telephone No. Email Address

Prior UD Service Yes No If Yes, service was Full time Part time Dates:

Employee Date: Signature: Revised March 2014