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)