Bloomsburg University of Pennsylvania
Bloomsburg, Pennsylvania 17815
Office of Human Resources and Labor Relations
Please complete the following information for inclusion in your personnel file. Return to the Office of
Human Resources and Labor Relations, Room 134, Waller Administration Building or email to
kseigfre@bloomu.edu.
EMERGENCY ADDRESSEE INFORMATION
EMPLOYEE INFORMATION: PLEASE PRINT OR TYPE
Personnel Number:
Date:
Work Ext:
Located on pay stub
Last Name:
First Name:
Middle Initial:
Address:
Street
City
State
Home Phone:
Zip Code
Cell Phone:
PERSON TO NOTIFY IN CASE OF EMERGENCY
Name:
Relationship:
Address:
Street
City
State
Home Phone:
Cell Phone:
Business Phone:
Place of Business:
Zip Code
Rev. 09/08