| Social Security
Number |
SSN:
-
-
|
Required for Fed & State tax reporting purposes
|
| Name
Info |
Title:
|
|
Enter
this information just as it appears on your Social Security Card |
First:
|
Middle:
|
Last:
|
| Permanent
Address |
Address:
|
This address will be used for mailing pay checks
|
City:
|
State:
|
Zip Code:
|
County: (ie, Coconino)
|
| Local
Mailing Address |
Address:
|
Enter Only if different from Permanent Address
This address will be used to mail W2 only if different than permanent address
|
City:
|
State:
|
Zip Code:
|
County: (ie, Coconino)
|
| Phone
Numbers |
Home:
-
-
|
NAU Work:
-
-
|
Please
use the following format:
928-523-1234
|
Pager:
-
-
|
Cell:
-
-
|
| Educational
Background |
Highest Educational Degree Completed:
|
| General
Information |
Gender:
Male
Female |
|
|
Do you smoke? (For insurance purposes)
Yes
No |
Marital Status:
|
What is your date of birth?
|
| Emergency
Contact Information |
Contact First Name:
|
Contact Last Name:
|
Emergency contacts
are typically parents, other close relatives, or close friends |
Relationship to Employee:
|
If you selected "other" please specify:
|
|
Same as employee permanent address
Different than employee permanent address (please list information below)
|
|
Address:
|
City:
|
County: (ie, Coconino)
|
State:
|
Zip Code:
|
Home Phone:
-
-
|
Daytime Phone:
-
-
|
Pager Number:
-
-
|
Cell Number:
-
-
|
| Optional Information |
Ethnicity:
Are you Hispanic or Latino?
Yes
No
Are you (mark all that apply)
White
Black
Asian
Native Hawaiian/Other Pacific Islander
American Indian/Alaskan Native
|
This section is voluntary. Submission of this information is voluntary and
refusal to provide it will not subject you to any adverse treatment. The
requested information is consistent with our obligations as a Government
contractor and needed to fulfill federal and state reporting requirements
and affirmative action monitoring. It will be kept confidential, except
as expressly allowed under the law.
Contact the Office of Affirmative Action & Equal Opportunity, (928) 523-7855, TTY (928)523-1006, regarding requests for accommodation and questions about the University’s affirmative action program.
|
Military Status:
Armed Forces Service Medal Veteran
Veteran of the Vietnam Era
Other Protected Veteran
Disabled Veteran
Discharge date
|
Citizenship:
Native
Naturalized
Alien, permanent
Alien, temporary (must verify employment status with Payroll Office) |
Individual with a Disability
Yes
No |
| Background |
Have you ever
been convicted of, plead guilty, or "no contest" to a crime that has or has not
been expunged from your record?
Yes
No
If yes, please explain:
|
|
