Human Resources Department
Joyal Administration, Rm 164
Fresno, Ca. 93740-8026
(559) 278-2032
EMPLOYEE STATISTICAL DATA
Dr.
Mr.
Ms.
Employee Name: ________________________________________________________________________
(Last)
(First)
(M.I.)
Address (if different from application, mailing or W-2): ___________________________________________________
(Street)
(City)
(State)
(Zip)
Home Phone: ______________________
Alternate Phone(s): ______________(work) or ___________________(cell)
Social Security#____-____-____
Date of Birth:____/____/____
Gender:
Female
Male
Highest Education Level:
Institution Name: ___________________________________________
Major: ____________________________________________________
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PH.D.
ED.D
J.D.
OTHER D
M.A.
M.B.A.
M.F.A.
M.L.S.
M.P.T.
M.P.A.
M.P.H.
M.S.
M.S.W.
OTHER M
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Doctor of Philosophy
Doctorate of Education
Doctor of Jurisprudence
Other Doctorate
Master of Arts
Master of Business Admin.
Master of Fine Arts
Master of Library Science
Master of Physical Therapy
Master of Public Admin.
Master of Public Health
Master of Science
Master of Social Work
Other Master
Languages In Addition To English: (Circle those that apply)
Able to Translate
ο BU
Burmese
ο
Speak (High/Low/Moderate)
ο CC
Chinese (Cantonese)
ο
Read (High/Low/Moderate)
ο CH
Chinese (Other)
ο
Write (High/Low/Moderate)
ο
CM
Chinese (Mandarin)
ο
CS
Chinese (Shanghai)
ο AF
Afrikaans
ο CZ
Czech
ο AM
Amharic
ο DA
Danish
ο AR
Arabic
ο Du
Dutch
ο
ASL American Sign Lang. ο EN
English
ο BH
Bahasa (Indonesian)
ο FA
Farsi (Persian)
ο BO
Bengali
ο
ο
ο
ο
ο
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State: _______________________
Month/Year Graduated: _________
B.S.
B.A.
OTHER B
P
A
Q
C
T
H
I
J
K
E
S
FL
FR
FS
GE
GR
HE
HI
HU
IA
IH
Bachelor of Science
Bachelor of Arts
Other Bachelor
Professional Degree
Associate Degree
Some College
Professional Certificate
Trade or Craft Certificate
High School Diploma or GED
Some High School
Junior High School Completed
Some Junior High School
Elementary School Completed
Some Elementary School
Flemish
French
Finnish
German
Greek
Hebrew
Hindi
Hungarian
Indian (Kannada)
Indian (Hindi)
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IK
IN
IT
JA
KI
KO
LA
LI
LO
LT
Indian (Konkani)
Indian
Italian
Japanese
Kiswahili
Korean
Latvian
Lithuanian
Laotian
Latin
1
An Equal Opportunity Employer & Educational Institution
Original: HR Technician
-
Copy: Payroll Department
Form Update 10/01/10
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MAL
NO
PH
PO
RO
RU
Malay
Norwegian
Polish
Portuguese
Rumanian
Russian
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ο
SI
SP
SR
SW
TA
TE
Swahili
Spanish
Serbo-Croatian
Swedish
Tagalog (Philippines)
Telugu
ο
ο
ο
ο
ο
ο
TH
TI
TM
TU
TW
UK
Thai
Tamil (India)
Tamil (Ceylon)
Turkish
Twi (Ghana)
Ukrainian
ο
ο
ο
UR
VI
WE
Urdu (Pakistan)
Vietnamese
Welsh
Payroll Information
Disability Status
Indicate your disability status by checking one of the following.
A.
Disabled Veteran, Vietnam Era
B.
Special Disabled Veteran, Not of Vietnam Era
C.
Other Eligible Veteran
N.
None of the Above
________________________________________________________________________________________________________
Alien Status
Check one of the following:
U.S. Citizen
I am not a U.S. Citizen. If you marked this box, complete the Visa Type below.
X. Visa Type
F.
Non-Citizen-Student Visa
Expiration Date:(Mo/Yr)___________
OON
Non-Resident
Expiration Date:(Mo/Yr)___________
OOR
Permanent Resident
J.
Non-Citizen-Exchange Visitor
D/S Enter 9999
Z.
All other types of Non-Citizen Visas (e.g. H-1B, TN)
CC
See Chart for Country Codes
Y. Tax Residence Code
R.
Resident
N.
Non-Resident
ZZZZ
Work Authorization end date (Mo/Yr)____________
________________________________________________________________________________________________________
This form will not be filed or maintained. The information requested is required for the CSUF systems data base
and will be destroyed once the information has been entered.
2
An Equal Opportunity Employer & Educational Institution
Original: HR Technician
-
Copy: Payroll Department
Form Update 10/01/10