BLACK HILLS STATE UNIVERSITY
Employee Personal Data Statement
Title________________________________________
Hire Date__________________________________
PERSONAL DATA
Name (as appears on your Social Security card) ___________________________________________________________________________________
Last
First
Date of Birth: _________________________
Middle
Place of Birth: _______________________________________
State
Country
Local Address______________________________________________________________________________
Street
City
State
Zip
Permanent Address _________________________________________________________________________
(If different)
Street
City
State
Zip
Email Address_____________________________________________________________________________________
Phone (
) ________________________________
YES
U.S. Citizen:
NO
YES
NO
Military Service:
If yes, Branch: ________________________________
Enlisted Date: _______________________________ Discharge Date: _______________________________
Enlisted Rank: _______________________________ Discharged Rank: _____________________________
YES
Are you a disabled veteran:
NO
STATEMENT of SELECTIVE SERVICE REGISTRATION
SDCL 3-1-1.1 requires draft registration compliance as a prerequisite to being hired by a South Dakota governmental
body or agency. Please check the appropriate statement.
I hereby certify that I am registered with the Selective Service pursuant to the Military Selective Service Act, 50
USC 453, as amended and in effect on January 1, 1988.
I certify that for a reason specified in 50 USC 453, I am not required to be registered. (Some of the reasons are
listed below).
* I am female
* I am in the armed services on active duty (Note: does
not apply to members of the Reserves and National
Guard who are not on active duty).
* I have not reached my 18th birthday
* I was born before 1960
* I am a citizen of the Federal States of Micronesia, the
Marshall Islands, or a permanent resident of the Trust
Territory of the Pacific Islands (Palau).
* I am a lawfully admitted nonimmigrant alien
EEO INFORMATION: Black Hills State University is an equal opportunity employer. Information requested in this
section will only be used for statistical and/or Affirmative Action purposes and will be treated as confidential.
Gender:
Male
Female
Marital Status:
Ethnicity:
Race:
Single
Married
Hispanic or Latino
American Indian
Asian
Divorced
Widowed
Legally Separated
Not Hispanic or Latino
Black/African American
Native Hawaiian/other Pacific Islander
White
EDUCATION
Please list educational institutions attended, beginning with the high school granting diploma.
Dates Attended
From
Mo Yr
To
Mo Yr
Location
Educational
Institution
Area of Study
Major
Dates
Conferred
Degree
Minor
Month
Year
PRIOR WORK EXPERIENCE with the STATE OF SOUTH DAKOTA:
Have you been previously employed by the State of South Dakota?
YES
NO
List any other name(s) used during previous employment with the state: _________________________
In order to assure credit for longevity and leave accrual please list past employment with the State of
South Dakota: (Please include any student employment while at a State University or summer employment with a State Agency
(example: Game, Fish, and Parks).
DEPARTMENT
LOCATION
JOB TITLE
FULL-TIME/
PART-TIME
APPOINTED
Mo Day Yr
TERMINATED
Mo Day Yr
(indicate one)
I certify that the forgoing answers are correct to the best of my knowledge and belief.
SIGNATURE________________________________________________________DATE________________
Human Resources
Black Hills State University
1200 University St Unit 9568
Spearfish SD 57799-9568
605.642.6549
(This form is retained in the employee’s permanent file.)