•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
–
•
–
–
–
–
–
•
•
•
•
•
•
•
–
•
•
–
•
•
•
–
–
–
•
•
–
Students are not permitted
to work overtime
•
•
•
•
•
•
•
Personal
Data
Form
Employee ID:
Effective Date:
SSN:
100001 xxx-xx-xxxx
03/10/2005
Nam e: (Last, First or Initial, Middle or Initial) (Name as it
appears on your Social Security Card)
Birth Date (mm/dd/yyyy):
Hom e Phone:
Gender:
Doe, John Paul
01/01/1901
Street/P.O. Box: (no t applicable fo r Students/Grads)
City: (no t applicable fo r
State:(no t applicable
Zip Code:(no t applicable
Students/Grads)
fo r Students/Grads)
fo r Students/Grads)
(A rea Co de) 888-8888
Direct Deposit Authorization
I authorize NIU to deposit any amounts owed to me into my account at the following depository institution. I authorize
NIU to debit my account only for the purpose of correcting an amount erroneously credited to my account. I understand
this authorization will remain in effect until I notify NIU in writing by completing a new Direct Deposit Authorization form.
TCF Bank
Financial Institution:
DeKalb, IL
,
(Name)
(Address)
271972572
Routing#:
1x111111x1
(Account Number)
Student Loan Status/Disclosure Education Loan Repayment (DELR)
Are you currently in default on the repayment of any state educational loan?
Applies to Non-Resident
Aliens Only
Citizenship
U.S. CITIZEN
LAWFUL PERMANENT RESIDENT
NON-RESIDENT ALIEN
Military Status
Citizenship Country
NO MILITARY SERVICE
ACTIVE RESERVES
INACTIVE RESERVES
Visa Type
Highest Educational Level
LESS THAN HIGH SCHOOL
HIGH SCHOOL GRAD/GED
TECH SCHOOL
SOME COLLEGE
2-YEAR COLLEGE
BACHELOR'S DEGREE
Ethnic
SOME GRADUATE WORK
MASTER'S DEGREE
MD, DDS, JD
DOCTORATE
POST DOCTORATE
AMERICAN INDIAN / ALASKA NATIVE
ASIAN
BLACK / AFRICAN AMERICAN
HISPANIC / LATINO
NATIVE HAWAIIAN / PACIFIC ISLANDER
WHITE / CAUCASIAN
Education History
Degree
Date
Major
School
Degree
Date
Major
School
Degree
Date
Major
School
Degree
Date
Major
School
Employee Signature
Employee Signature:
VIETNAM VETERAN
OTHER VETERAN
RETIRED
Date:
•
–
–
–
–