E I F Employee Information Form - Pcc Human Resources Department

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E I F
Employee Information Form
PCC Human Resources Department
ID/SSN
New Hire
Rehire
Change-other ___________________
Effective Date ___________________
Name _____________________________________________
Previous Name ________________________
(if applicable)
Last
First
MI
Date of Birth _______________________________
Preferred First Name __________________
The following race, ethnic and gender information is used for EEO statistical purposes and general reporting only
Do you consider yourself to be Hispanic/Latino?
Yes
Sex:
No
Male
In addition, select one or more of the following racial categories to declare yourself:
Female
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
The Department of Labor has asked employers to report Veteran status of our employees. The regulations provide
that this information be voluntarily obtained from employees.
Please check all categories that you qualify for:
Duty Separation Date is _________________________
Veteran of the Vietnam Era
Other (eligible) Veteran
Both Vietnam/Other Protected Veteran
Special Disabled Veteran
Mailing Address:
Street __________________________________
Home Telephone: ( _____ ) ________________
__________________________________ Campus Address: _________________________________
Campus
Building
Room
__________________________________ Campus Telephone: ______________________
City
State
Zip
Confidential
Yes
No
•
If you indicate “NO”, you are authorizing disclosure of your address and
telephone number to any member of the public upon request.
• If you indicate “YES” you are voluntarily submitting your address and telephone
number in confidence and believe that release of this information to members of the
public would be an unreasonable invasion of your personal privacy and/or safety. By
indicating “YES”, you may miss some mail or call you would have wished to receive.
Emergency Contact Information:
Primary - (local if possible) Relationship ________________________
Secondary – optional
Relationship ______________________
Name __________________________________________
Name __________________________________________
Address ________________________________________
Address ________________________________________
________________________________________
________________________________________
City
State
Zip
City
State
Zip
Telephone ( _______ ) __________________
Telephone ( _______ ) __________________
Employee Signature __________________________________________________________ Date ________________
971-722-5867
Send to HRIS, Downtown Center 321
Questions? Call HR at
10/14/10

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