Mcc-210b Employee Information Form
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1Employee Information Form
Employee Name (Last, First, Middle) _____________________________________________________________________ Employee # ______________________
Street Address (City, State, Zip) _______________________________________________________________________________________________________________
Mailing Address _______________________________________________________________________________________________________________________________
Home Phone # ___________________________
Business Phone # _________________________________
Cell Phone # _____________________________
Social Security # ______________________________________________________________________________________________________________________________
In case of emergency, contact ______________________________________________________________ Phone # ______________________________________
Mitchell recently implemented an emergency notification text messaging system. The system will be used to send out notifications in
case of emergency and weather-related closings or delays. This notification is for the College to notify YOU.
Your notification contact # __________________________________________________________________
Do you have previous state service?
Yes
No
Have you retired from NC state service?
Yes*
No
*If so, what are your hire ____________________________________
and retirement ______________________________________ dates?
New Employee
Date of Birth ___________________________________________
Male
Female
Physically Handicapped?
Yes
No
Do you consider yourself to be Hispanic/Latino?
Yes
No
In addition, select one or more of the following racial categories to describe yourself:
Non-resident Alien
Asian
White
Hispanic/Latino
Black or African-American
American Indian or Alaskan Native
Native Hawaiian or Other Pacific Islander
Education (check one)
Less than high school
High school or equivalent
One year of college
Vocational diploma
Two years of college
Three-four years of college
Associate’s degree
Bachelor’s degree
Master’s degree
Doctoral degree
Educational specialist
Are you a U.S. citizen or a permanent resident alien?
Yes
No OR non-resident alien?
Yes
No
TO BE COMPLETED BY DEPARTMENT
Effective Date
___________________________________________________________
Contract Length ______________________________________________
New employee
Return to active status
Other (be specific)
Job Title _____________________________________________________________________________________________________________________________________
Status (check one)
FTF
FTS
PTS
PTF
FTT
RTA
Budget Code _____________________________________________________________________________________________________
$ __________________ /hour
P/T Student
F/T Student
Non-student
FACL status: STUD (full- or part-time student employee, not FWS)
TO BE COMPLETED BY HUMAN RESOURCES
Dept. _________________________________ EEOC Code __________________________
Location ____________________________________________________
Area of Instruction ____________________________________________________________________________________________________________________________
Position ____________________________________________________________________
Leave Plans ___________________________________________________
Pay cycle
FT
PT
Contract Length ______________________________________________
Code
Hourly
Salary
Account# ___________________________________________________________________
Account # ____________________________________________________
Classification _______________________________________________________________
Account # ____________________________________________________
Tax Status and Exemptions W4
____
NC4 __________________________________________________________
Deductions
Retirement ____________________ Hospitalization ______________________ Dental _________________
Other ___________________
SVM _________________________________
DRUS _________________________________________
Equal Opportunity College/Affirmative Action Employer
MCC-210B
Rev. 04/16
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Parent category: Business