Appointee Information Form

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Appointee Information Form
Personal Information (PLEASE PRINT)
Social Security Number: ________________________________________ Date of Birth: ____________________________________
Last Name: _________________________________ First: ________________________________ Middle: _____________________
Address: ____________________________________________________________________________________________________
City: __________________________________ County: _______________________ State: ________________ Zip: _____________
Home Phone Number: _____________________________________ Gender:
Male
Female
Email Address: _______________________________________ Mobile/Cell/Pager Number: _________________________________
Ethnicity:
Military Status:
Disabling Condition:
Citizenship:
American Indian/Alaska Native
Non-Veteran
No Disability
U.S. Citizen
Asian/Pacific Islander
Veteran
Disabled Veteran
Non-Resident Alien
African American (Not of Hispanic Origin)
Vietnam Veteran
Hearing Impaired
Permanent Resident
Hispanic/Latin American
Active Reserve
Speech Impaired
Pending Permanent
White (Not of Hispanic Origin)
Inactive Reserve
Vision Impaired
Asylum/Refugee Applicant
Undeclared/Unknown
Retired
Other
Other
Retired from State:
Yes
No
Citizenship/Visa Status: __________________________________ Citizenship Country: ____________________________________
I-94/Work Authorization or Permanent Resident # : _______________________________ Expiration Date: _____________________
Educational Information
Highest Level of Education:
ADV Graduate Specialist (AGS)
Some Business College Trade (HS Graduate)
Less than 7th Grade
Master’s Degree Earned
Associate Degree Earned
7th 8th 9th Grade Completed
Doctoral Degree Earned
Bachelor’s Degree Earned
10th 11th Grade Completed
First Professional Degree Earned
Some Graduate Study
High School Graduate or GED
Institution Name & State
Major
Degree
Date (yyyy/mm)
Current Educational Enrollment: (Complete only if currently enrolled in an educational program)
Undergraduate
Graduate
Doctoral
Other, Explain
_________________________
Emergency Contact Information
Name: ___________________________________________________ Relationship: ________________________________________
Address: ____________________________________________________________________________________________________
City: ______________________________________________________ State: ________________________ Zip: ________________
Home Phone: ______________________________________ Mobile/Cell/Pager Number: ___________________________________
Email Address: _______________________________________________________________________________________________
____________________________________________________________________________________________________________
Employee Signature
Date
Last Modified: July 2013

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