Employee Profile Form
Items on this page are REQUIRED to be completed.
Salutation:
Ms.
Mrs.
Mr.
Dr.
Rev.
Last Name:
First Name:
Middle Name:
(Nickname or name you wished to be known by:
Address: Street1:
Street2:
City:
Zip Code:
Start Date:
Citizenship:
Social Security #
Sex:
Male
Birthdate:
Suffix:
Female
)
State:
Phone:
Cell Phone:
Position:
U.S. Citizen
Permanent Resident/
Green Card Holder
Resident Alien
(living in U.S.)
Non-Resident Alien
(not living in U.S.)
Citizenship Country:
Alien Registration #:
Visa Type:
H1-B
Citizenship Country:
Year(s) Living in U.S.:
Visa Type:
H1-B
Citizenship Country:
F1
J1
Other
F1
J1
Other
In Case of an Emergency Notify:
(Additions, deletions and updates can also be made via Employee Self-Service on MC Square)
Name #1
Phone #1
Phone #2
Phone #3
Name #2
Phone #1
Phone #2
Phone #3
Physician
Document1
Relationship
Phone Type
Phone Type
Phone Type
Relationship
Phone Type
Phone Type
Phone Type
Phone
Home
Home
Home
Work
Work
Work
Cell
Cell
Cell
Home
Home
Home
Work
Work
Work
Cell
Cell
Cell
Rev. 01/16
Invitation to Self-Identify
Submission of this information is voluntary and failure to provide will not subject you to any adverse treatment.
As such, information you submit will be kept confidential except that supervisors may be informed regarding
restrictions on work or duties as related to disability and regarding necessary accommodations; (ii) first-aid
personnel may be informed, when and to the extent appropriate, if a condition might require emergency treatment,
and (iii) government officials as required when engaged in enforcing laws administered by the Human Relations
Commissions.
Please check all applicable ethnicity AND race boxes if providing information:
I prefer not to self-identify my ethnicity or race
Ethnicity:
Hispanic or Latino*
Not Hispanic or Latino
* Includes Cuban, Mexican, Puerto Rican,
South or Central American, or other Spanish
culture or origin, regardless of race
Race:
(Select one or
more of the
applicable race
categories)
American Indian or Alaska Native
American Indian
Alaskan Native
Choctaw
Cherokee
Chippewa
Navajo
Sioux
Other American Indian
Asian or Asian American
Asian American
Asian
Chinese
Cambodian
Filipino
Hmong
Indian (subcontinent)
Japanese
Korean
Malaysian
Pakistani
Thai
Vietnamese
Other Asian
Black or African American
African American
Black
African
Carribean
Other Black/African American
Native Hawaiian or
Other Pacific Islander
Guamanian
Native Hawaiian
Other Pacific Islander
Pacific Islander
Samoan
Hispanic or Latino*
Central American
Chicano/a
Cuban
Hispanic or Latino/a
Mexican, Mexican-American
Puerto Rican
South American
Spanish (Spain)
Other Hispanic or Latino/a
White
European
Middle Eastern
North African
White-Caucasian
Other White, Non-Hispanic
NOTE: Ethnicity and primary race categories listed are per federal regulations.
Document1
Rev. 01/16
Invitation to Self-Identify
Veteran
Status:
Disability:
Vietnam Veteran
Vietnam & Other Veteran
Other Protected Veteran
I have a disability
I would like to make a request for
reasonable accommodation
Yes
No
Yes
No
Messiah College’s plan is designed to ensure Messiah College employees have equal opportunities to apply for
positions at Messiah College; and are accorded reasonable accommodations when necessary to enable them to safely
perform the essential functions of any position for which they qualify.
Employee Signature
Document1
Date
Rev. 01/16