New Employee Data Form

Virginia State University

(Please check one) Type of Employment: • Faculty Administrator • Faculty • Classified • Hourly • Adjunct Personal Data: Last Name: First Name: Middle Initial:

Social Security Number: Home Phone: Personal Email Address:

Gender: Date of Birth:

Physical Address: (Street) P.O. Box: (for mailing only)

(City) (State) (Zip Code) Credentials: (Please check highest level of education) • High School • Associates • Bachelors • Master’s • Doctorate

Contact Information:

In case of emergency:

Contact Person: Relationship: Contact Phone Number(s):

Race (Circle One): • • - White (includes Arabs) • • - Black (includes Jamaicans, Bahamians, and other Caribbean’s or African but not Hispanic or Arabian descent) • • - Hispanic (Spanish surname, includes Mexican, Puerto Rican, Cuban, Central or South American or other Spanish Origin or culture) • • - Asian or Asian American (includes Pakistan, Indians, and Pacific Islanders) • • - American Indian and Alaskan Native

Employee’s citizenship status (Check One): • U.S. Citizen - C • Resident Alien - A • Non-resident Alien – N Other Status: Nationality Code (See Back): ______

Prior State Employment: Yes _o / No • Please check one: Type of State Employment: • Faculty Administrator • Faculty • Classified • Hourly • Adjunct Dates: If yes, State Agency Name: (This information will only be used to ensure all employment records are transferred) Work Information:

Position Title: Position Number (if known): Department: Supervisor’s Name and Title

Campus Box No. : Building Location: Room # Work Number: VSU Email:

Employee’s Signature 06/04/2007 If any information should change during your employment please contact HR NATIONALITIES: AF Afghanistan CT Central African Republic GG Georgia LG Latvia MU Oman WZ Swaziland AL Albania CD Chad GM Germany LE Lebanon SW Sweden AG Algeria CI Chile GH Ghana LT Lesotho PK Pakistan SZ Switzerland AQ American Samoa TW China (Taiwan) GI Gibraltar LI Liberia LQ Palmyra Atoll SY Syria AN Andorra CH China GO Glorioso Islands LY Libya PM Panama AO Angola KT Christmas Island GR Greece LS Liechtenstein PP Papua New Guinea TW Taiwan AV Anguilla IP Clipperton Island GL Greenland LH Lithuania PF Paracel Islands TI Tajikistan AY Antartica CK Cocos (Keeling) Islands GJ Grenada LU Luxembourg PA Paraguay TZ Tanzania AC Antigua & Barbuda CO Colombia GP Guadeloupe PE Peru TH Thailand AR Argentina CN Comoros GQ Guam MK Macedonia RP Philippines TO Togo AM Armenia CF Congo GT Guatemala MC Macau PC Pitcairn Island TL Tokelau Islands AA Aruba CW Cook Islands GK Guernsey MA Madagascar PL Poland TN Tonga AT Ashmore & Cartier CR Coral Sea Islands GV Guinea MI Malawi PO Portugal TD Trinidad & Tobago Islands CS Costa Rica PU Guinea-Bissau MY Malaysia RQ Puerto Rico TE Tromelin Island MV Maldives PS Trust Territory of the AS Australia IV Cote d’Ivoire GY Guyana QA Qatar AU Austria HR Croatia ML Mali Pacific Islands AJ Azerbaijan CU Cuba HA Haiti MT Malta RE Reunion TS Tunisia CY Cyprus HM Heard Island & IM Man, Isle of RO Romania TU Turkey BF Bahamas, The EZ Czech Republic McDonald Islands RM Marshall Islands RS Russia TX Turkmenistan BA Bahrain HO Honduras MB Martinique RW Rwanda TK Turks & Caicos Islands FQ Baker Island DA Denmark HK Hong Kong MR Mauritania TV Tuvalu BG Bangladesh DJ Djibouti HU Hungary MP Mauritius SC St. Kitts & Nevis BB Barbados DO Dominica MF Mayotte UG Uganda IC Iceland SH St. Helena UP Ukraine BS Bassas da India DR Dominican Republic MX Mexico ST St. Lucia BO Belarus IN India MQ Midway Islands TC United Arab Emirates EC Ecuador ID Indonesia SB St. Pierre & Miquelon UK United Kingdom BE Belgium MD Moldova Islands VC St. Vincent & The BH Belize EG Egypt IR Iran MN Monaco US United States ES El Salvad or IZ Iraq Grenadines UY Uruguay BN Benin MG Mongolia SM San Marino BD Bermuda EK Equatorial Guinea EI Ireland MW Montenegro UZ Uzbekistan ER Eritrea IS Israel TP Sao Tome & Principe BT Bhutan MH Montserrat SA Saudi Arabia BL Bolivia EN Estonia IT Italy MO Morocco NH Vanuatu ET Ethiopia SG Senegal VT Vatican City BK Bosnia and JM Jamaica MZ Mozambique SR Serbia Herzegovina EU Europa Island VE Venezuela JA Japan WA Namibia SE Seychelles VM Vietnam BC Botswana FK Falkland Islands (Islas DQ Jarvis Island SL Sierra Leone BV Bouvet Island NR Nauru VQ Virgin Islands of the Malvinas) JE Jersey BQ Navassa Island SN Singapore U.S. BR Brazil FO Faroe Islands JQ Johnston Atoll LO Slovakia IO British Indian Ocean NP Nepal FM Federated States of JO Jordan NL Netherlands SI Slovenia WQ Wake Island Territory Micronesia JU Juan de Nova Island GP Solomon Islands WF Wallis and Futuna VI British Virgin Islands NT Netherlands Antiles FJ Fiji NC New Caledonia SO Somalia WE West Bank BX Brunei FI Finland KZ Kazakhstan SF South Africa WI Western Sahara BU Bulgaria KE Kenya NZ New Zealand FR France NU Nicaragua SX South Georgia & the WS Western Samoa UV Burkina FG French Guiana KQ Kingman Reef South Sandwich BM Burma KR Kiribati NG Niger YM Yemen FP French Polynesia NI Nigeria Islands BY Burundi FS French Southern & KN Korea, Democratic SP Spain Peoples Republic of NE Niue CG Zaire CB Cambodia Antarctic Lands NF Norfolk Island PG Spratly Islands ZA Zambia KS Korea, Republic of CE Sri Lanka CM Cameroon GB Gabon KU Kuwait CQ Northern Mariana ZI Zimbabwe CA Canada Islands SU Sudan GA Gambia, The KG Kyrgyzstan NS Suriname CV Cape Verde GZ Gaza Strip LA Laos NO Norway CJ Cayman Islands SV Svalbard

Page 2 of 2 01/01/2018 HR If any information should change during your employment please contact HR