CALIFORNIA STATE POLYTECHNIC UNIVERSITY, POMONA

CALIFORNIA STATE POLYTECHNIC UNIVERSITY, POMONA PERSONAL DATA FORM Today's Date _____________________________________ Maiden Name Employee's Full Name ____________________________________________________ or Aliases ___________________________ SSN Social Security No. _________________________________ VERIFIED Payroll Use Only

Phone (

) ________________________

Address __________________________________________ City __________________________________ Zip ________________ Country of Citizenship _____________________________________ Non-U.S. Citizen Visa _____________________________________ (Type & Expiration) Sex: M

F



Birthdate _________________________

Driver's Expiration License No. ________________________ Date _______________ Certificate, Registration, Special Expiration Professional License No. ______________ Date _______________ Highest Education Level Attained as of Today's Date __________________

Date of Graduation or Degree ___________

Institution Granting Degree _________________________________

(Indicate Specific Campus)

Last Place of Employment __________________________________ Prior California State Service? Yes

No

If yes, name of employing agency ___________________________ Were you ever a member of Public Employees' Retirement System? Yes ____ No ____ Were you ever a member of State Teachers' Retirement System? Yes ____ No ____ If yes, are your funds still on deposit? Yes ____ No ____ Are you a retired member of PERS? Yes ____ No ____ Are you a retired member of STRS? Yes ____ No ____

Do you have a disability?

Yes

No

If 'yes' please complete the Employee Disability Status Survey. Are you a Veteran?

Yes

No

If yes, please complete the Veterans Survey. ETHNICITY

(Circle one letter from below)

Ethnic Race/Ethnicity Group

Employee *Dept. Self-Identification I.D.

Black

Black

F

1

Asian

Asian Indian (India, Pakistan, Bangladesh) Cambodian Chinese Japanese Korean Laotian Vietnamese Other

M U J I K Y L S

2

X

3 4

Other Other Non-White Non-White Hispanic

Cuban Mexican, MexicanAmerican/Chicano Puerto Rican Other

C

White

White

E

5

Pacific Islander

Guamanian/Chamorro Hawaiian Samoan Other

R P Q T

6

American Indian

American Indian Aleut Eskimo

H O N

7

Filipino

Filipino

G

8

A B D

*For use only if employee Self-Identification not completed.

IN CASE OF OF EMERGENCY NOTIFY Name _______________________________________________________ Relationship ____________________________________ Address ___________________________________ City/State _______________________________ Zip ______________________ Home Phone (

) _____________________________________ Work Phone (

) ____________________________________ F-1049-11 Rev. 2-00