CALIFORNIA STATE POLYTECHNIC UNIVERSITY, POMONA

CALIFORNIA STATE POLYTECHNIC UNIVERSITY, POMONA
PERSONAL DATA FORM
Today's Date _____________________________________
Maiden Name
Employee's Full Name ____________________________________________________ or Aliases ___________________________
SSN
Social Security No. _________________________________ VERIFIED Payroll Use Only
Phone (
) ________________________
Address __________________________________________ City __________________________________ Zip ________________
Country of Citizenship _____________________________________
Non-U.S. Citizen Visa _____________________________________
(Type & Expiration)
Sex: M
F
Birthdate _________________________
Driver's
Expiration
License No. ________________________ Date _______________
Certificate, Registration, Special
Expiration
Professional License No. ______________ Date _______________
Highest Education Level Attained as
of Today's Date __________________
Date of Graduation
or Degree ___________
Institution Granting Degree _________________________________
(Indicate Specific Campus)
Last Place of Employment __________________________________
Prior California State Service? Yes
No
If yes, name of employing agency ___________________________
Were you ever a member of Public Employees' Retirement System?
Yes ____ No ____
Were you ever a member of State Teachers' Retirement System?
Yes ____ No ____
If yes, are your funds still on deposit? Yes ____ No ____
Are you a retired member of PERS? Yes ____ No ____
Are you a retired member of STRS? Yes ____ No ____
Do you have a disability?
Yes
No
If 'yes' please complete the Employee Disability Status
Survey.
Are you a Veteran?
Yes
No
If yes, please complete the Veterans Survey.
ETHNICITY (Circle one
letter from below)
Ethnic
Race/Ethnicity
Group
Employee
*Dept.
Self-Identification I.D.
Black
Black
F
1
Asian
Asian Indian (India,
Pakistan, Bangladesh)
Cambodian
Chinese
Japanese
Korean
Laotian
Vietnamese
Other
M
U
J
I
K
Y
L
S
2
X
3
4
Other
Other Non-White
Non-White
Hispanic
Cuban
Mexican, MexicanAmerican/Chicano
Puerto Rican
Other
C
White
White
E
5
Pacific Islander
Guamanian/Chamorro
Hawaiian
Samoan
Other
R
P
Q
T
6
American
Indian
American Indian
Aleut
Eskimo
H
O
N
7
Filipino
Filipino
G
8
A
B
D
*For use only if employee Self-Identification not completed.
IN CASE OF OF EMERGENCY NOTIFY
Name _______________________________________________________ Relationship ____________________________________
Address ___________________________________ City/State _______________________________ Zip ______________________
Home Phone (
) _____________________________________ Work Phone (
) ____________________________________
F-1049-11 Rev. 2-00