Campus
PERSONAL DATA FORM
UCDHS
UPAY544 (R9/01)
N2
Date
MO
(13-18)
|
DY
| YR
Department
Prior Name
CHECK BOX IF NAME CHANGE:
N1
Employee ID (4-12)
Employee First Name: (19-48)
Employee Middle Name
(49-78)
Employee Last Name: (19-48)
Employee Name Suffix
(49-52)
PERSONNEL
PROGRAM
CODE
A-Academic
1-Professional
2-Management
A. TYPE OF ACTION (Check appropriate box.)
B.
EMPLOYMENT
DATA CHANGE
(Complete all Information.)
ADDRESS INFORMATION
YOUR PERMANENT MAILING ADDRESS
Line 1 - Street Address (19-48)
P2
TERMINATION
(Complete permanent address.)
CAMPUS MAILING ADDRESS
Campus (49-52)
Room No. (53-58)
Building
(59-68)
(1-2)
P3
Line 2 - Street Address (19-48)
US ONLY
State
(40-41)
City
Zip Code (42-46)
Campus Phone 1
(49-58)
Campus Phone 2 (56-98)
(1-2)
P4
(19-39)
(19-28)
Spouse's Name
(29-53)
(1-2)
FOREIGN (47)
COMPLETE ONLY IF YOUR MAILING
ADDRESS IS OUTSIDE THE US
SEE REVERSE FOR DISCLOSURE OF INFORMATION
EMPLOYEE ORGANIZATIONS
FOREIGN Province, State, County, Shire District,
Region, etc. (48-62)
Foreign Postal
Code (63-72)
YES
NO
YES
NO
Do you want your home address released
to employee organizations?
(57)
Do you want your home phone released to
employee organizations?
(58)
Code
(73-74)
Foreign Country
C.
Home Phone (Local)
P5
(1-2)
TO RELEASE INFORMATION FOR OFFICIAL
CAMPUS USE, CHECK APPROPRIATE BOX:
Permanent Address
(59)
Home Phone
(60)
Spouse's Name
(61)
EMERGENCY DATA
PERSON TO BE NOTIFIED IN CASE OF EMERGENCY
PA Name
Relationship
(1-2)
Street Address
PB
Phone 1
(1-2)
City
PC
State
ZIP Code
Phone 2
(1-2)
D.
STUDENT STATUS AND EDUCATION
UC STUDENT STATUS ---------(19) -----
P8
(1-2)
E.
Female
US Citizen?
YES
Date Entered US
VISA Status
NO
N
H
T
A
No Acad Cert
HS or Equiv.
Trade Cert.
Assoc.
MO
Intended Length of Stay
B
M
P
D
Bach.
Mast.
Prof.
Doct.
Year Awarded
(21-22)
20
G.
From
To
|
RELATIVES EMPLOYED AT UC?
INDICATE NAME, RELATIONSHIP + DEPARTMENT
Employed
MO
Country of Residency
| DY | YR
PRIOR EMPLOYMENT (Other than UC or State)
Employer Name
H.
Mark Highest
Degree Only:
PERSONAL INFORMATION AND CITIZENSHIP STATUS
Male
F.
Units this
Term
1-Not Registered
5-Not Reg Deg Cand /
2-Not Reg Deg Cand
Other Campus
3-Undergraduate
6-Undergrad/Other Campus
4-Graduate
7-Grad / Other Campus
YR
MO
YES
|
YR
NO
PRIOR OR CONCURRENT UC/STATE EMPLOYMENT (Include ERDA Labs)
Employed From - To
Campus
Department
Retirement System
Enter Name if Different Than Above
MO | DY | YR | MO | DY | YR
I.
PA
LICENSE
License Number
Type Code
Expiration Date
(1-2)
MO | DY | YR
RETN: Accounting: 1 year after modification
Other Copies: 0-5 yrs after modification
EMPLOYEE
SIGNATURE:
SEE REVERSE SIDE FOR PRIVACY NOTIFICATION
DATE:
PRIVACY NOTIFICATION
STATE
The State of California Information Practices Act of 1977 (effective July 1, 1978) requires the University to provide the following information to
individuals who are asked to supply information:
The principal purpose for requesting the information on this form is for payment of earnings, and for miscellaneous payroll and personnel
matters, such as, but not limited to withholding of taxes, benefits, administration, and changes in title and pay status. University policy and State
and Federal statues authorize the maintenance of this information.
Furnishing all information requested on this form is mandatory--failure to provide such information will delay or may even prevent completion of
the action for which the form is being filled out. Information furnished on this form may be used by various University departments for payroll
and personnel administration, and will be transmitted to the Federal and State governments as required by law.
Individuals have the right to review their own records in accordance with Staff Personnel Policy 605 and Academic Personnel Manual Section
160. Information on these policies can be obtained from Campus or Office of the President Staff and Academic Personnel Offices.
The officials responsible for maintaining the information contained on this form are: Office of the President and Campus Academic and Staff
Personnel Managers or Campus Accounting Officers.
DISCLOSURE OF INFORMATION
If you want your Permanent address released to employee organizations (unions), mark "X" in the "DO" box. If you do not want your permanent
address released to employee organizations (unions), mark "X" in the "DON'T" box. Failure to complete this area on the form will mean that
your permanent address may be released to employee organizations upon request from unions.