Personal Data Form

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Revised: January 30, 2017
PERSONAL DATA FORM (PDF)
The Personal Data Form (PDF) is used to record the personal information for all employees. Seton Hall University is an equal opportunity employer and is required by federal law to
report certain data. All information is reported in statistical form only. Please refer to the reverse side of this form for an explanation of selected terms. After completing, please sign,
date and return to the Department of Human Resources, Martin House 366 South Orange Avenue, South Orange, NJ 07079
SHU ID #:
________________________________________
Check appropriate box:
Hire/Effective Date:
___________________________________
New Hire/Rehire
Employment Status Change
Office Telephone #:
___________________________________
Name Change Only
PERSONAL DATA
Mr.
Mrs.
Ms.
Miss
Dr.
Monsignor
Reverend
Sister
Brother
Date of Birth _____________/_________/_________________
Social Security Number _____________ - ________ - ________________
___________________________________________
_____________________________________
_______
Last Name
First Name
M.I
NAME CHANGE: Legal documentation indicating name change is required for a list of acceptable documents see reverse side
________________________________________________
________________________________________________________
New Last Name
New First Name/ Middle Initial
__________________________________________
_______________________________
_______
___________
Address
City
State
Zip Code
__________________
(______) ________-__________
(______) ________-__________
County
Home Telephone Number
Cell Phone Number
Are you working outside of New Jersey? ________ If yes, what State or Country ________________________
Ethnicity (See reverse for definition)
Sex
US
. Veteran Status
Military Reserve Status
Hispanic or Latino
Male
Not in Military Reserve
Non Veteran
Not Hispanic or Latino
Female
Active
Vietnam Veteran Only
Race (Select all that apply)
Inactive-Subject to call
Other Protected Veteran Only
Inactive
American Indian or Alaska Native
Both Vietnam/Other Eligible Veteran
Asian
Armed Forces Services Medal Indicator
Black or African American
Special Disabled Veteran
Veteran File Number: __________________
Native Hawaiian or Other Pacific Islander
White
Active Duty Separation Date: ___________
EMERGENCY CONTACT
________________________________
______________
(_______) ________________
(_______) ________________
Name
Relationship
Contact Number 1
Contact Number 2
________________________________
______________
(_______) ________________
(_______) ________________
Name
Relationship
Contact Number 1
Contact Number 2
EDUCATION
_______________________________
_________/_______/____
___________________________________________
Degree
Date Conferred
Granting Institution
_____________________________________
_________/_______/________
___________________________________________________
Degree
Date Conferred
Granting Institution
____________________________________
_________/_______/________
___________________________________________________
Degree
Date Conferred
Granting Institution
___________________________________
_________/_______/________
___________________________________________________
Certificate/License
Date Conferred
Granting Institution
_____________________________________________________
______/________/_________
Signature of Employee
Date

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