New York University Department of Chemistry

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New York University Department of Chemistry
NEW PERSONNEL INFORMATION SHEET
Please print clearly and return completed form to Irene Kiriazi.
POST DOC STUDENTS ONLY FILL OUT THIS FORM
Today’s Date:
Name:__________________________________________
NYU ID# (located in the back of the ID card): N_______________________
Date of Birth (mm/dd/yy):_______________ Gender (Please Circle One): Male/Female
Ethnicity (optional) please circle one:
Asian, African American, Caucasian,
Hispanic, Native-American, Pacific Islander
Other_______________________________
NYU is subject to certain governmental record keeping and reporting requirements
for the administration of civil rights laws and regulations. In order to comply with
these laws, NYU invites applicants to voluntarily self-identify their race or ethnicity,
and legal gender. This information will be kept confidential
**Give expected date of graduation or departure_____________________**
Home Address (in NYC): _________________________________________
Home Telephone Number: (in NYC) ________________________________
Work (Lab/Office working in) Address: _______________________
Work (Lab/Office,) Telephone: ______________________________
NYU Email Address (required):________________________
Name of Advisor or Supervisor: ________________________
Emergency Contact (name, relationship, telephone number):
________________________________________________________________
Signature of Advisor or Supervisor:____________________________________
Assigned Laboratory Room and/or Office:______________________________
**Please check here  if you need to be included on the chemtech email list**
(For users of departmental instrumentation)
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