HUMAN RESOURCES PERSONAL INFORMATION FORM – FACULTY/STAFF
THIS FORM MUST BE COMPLETED ON A COMPUTER
Date: 7/1/2016
Required Personal Email address:
*Use the spacebar or click to “check” boxes throughout the form*
Please check
New Hire
Rehire
Making a Change of Address
Name Change
The information provided on this form is used for University benefits, tax information, service awards, mail,
telephone directory, and for all University and government reporting. It is essential that all elements be
accurate and truthful. Your name printed on this form and tax forms must match the legal name printed
on your social security card.
Human Resources may request to view your social security card or legal name change document to verify that
your name is correctly recorded in the system.
PLEASE PRINT YOUR INFORMATION
Social Security Number:
- -
Department:
Name:
(First, Middle, Last, Suffix if needed) Use Legal Name
Preferred first name:
Maiden Name:
ROMAN CATHOLIC RELIGIOUS AFFILIATION (If applicable)
R1- Society of Jesus
R2- Other Religious Order
R3-Priest (diocesan)
ADDRESS INFORMATION MUST BE EITHER – HOUSE OR APT.
Permanent Address:
(NO CAMPUS ADDRESSES – NO BUSCH CENTER MSC #’S)
City and State:
Zip Code:
Permanent Telephone:
PERSONAL INFORMATION (Please Check Selection)
Marital Status:
Birth Date:
Gender:
Married
Widowed
/
/
Female
Male
Single
Divorced
Separated
Religious Order
Life Partnered
Citizenship:
Non- Citizen
If no, country of origin:
Visa Type:
Passport Expiration:
Visa Expiration Date:
Citizen
Non- Citizen Permanent Resident
VOLUNTARY DEMOGRAPHIC DATA (Release of demographic information is voluntary). The information obtained will be
kept confidential and may only be used in accordance with provisions of applicable laws.
Ethnicity: Are you Hispanic or Latino? (check only one)
Yes
No
Not Disclosed
Race: Review each of the following categories and check the box that identifies your race/national origin (you
may select more than one category).
White (not Hispanic or Latino)
Black or African American (not Hispanic or Latino)
Native Hawaiian or other Pacific Islander (not Hispanic or Latino)
Asian (not Hispanic or Latino)
American Indian or Alaska Native (not Hispanic or Latino)
Not Disclosed
Disability: Are you an individual with a disability?
Yes
No
Not Disclosed
If you selected “Yes”, please describe:
If you think you may need accommodations, please contact Human Resources for assistance.
Veteran Status: Review each of the following categories and check the box that identifies your veteran status
(you may select more than one category).
Non-Veteran
Disabled Vietnam
Special Disabled Veteran
Armed Forces Service Medal Veteran (If you selected “Armed Forces Service Medal Veteran”, please
provide the name of the Expedition or Campaign:
)
Vietnam-Era Veteran
Recently Separated Veteran (If you selected Recently Separated Veteran, please provide your date of
separation: MM/DD/YY: / /
)
Other Protected Veteran
Not Disclosed
Military Status :
Active Reserve
Active National Guard
Inactive National Guard
Does Not Apply to ME
Inactive Reserve
Inactive Nat. Guard-subject
to call up
Not in Active Reserve
EMERGENCY CONTACT
Name:
Relationship:
Telephone:
Home:
Cellular:
Work:
Other:
EDUCATIONAL BACKGROUND
(please list Undergrad, Graduate, and/or Professional, and Post Graduate in Order)
School
Date
Graduated
Undergrad
/
/
Graduate
/
/
Post Grad.
/
Degree
For Office
Use Only
Specialty:
Date:
/
/
Board Certified:
Date:
/
/
NAME OF SPOUSE OR CHILDREN
(This information is needed for benefits administration)
Name
Birth Date
/
/
/
/
/
/
/
/
Social Security
Number
- -
Relationship
- - - -
I certify that the information provided in this form is correct.
Signature_____________________________________Date_______________________
Saint Louis University is an Equal Opportunity Affirmative Action Employer.