Personal Information Form
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1 WELCOME TO THE DEPT OF _____________
PERSONAL INFORMATION
(This information is required to enter you onto the HR/Payroll system)
Name: _______________________________
Maiden/Prior Last Name: _______________________
Mailing Address:_______________________
City/St/Zip:__________________________________
Home Address:________________________
City/St/Zip:__________________________________
Home Phone: ________________________
Alternate Phone: _____________________________
Personal E-Mail (optional): ____________________
If you prefer to go by a name other than what is listed on your Social Security Card,
please indicate that preferred name below.
Preferred First Name:
Preferred Middle Name:
Suffix - Jr. or Sr. (if applicable):_________________________
Have you ever been employed by the State of Utah?
YES
NO
Are you receiving a retirement check/pension from Utah Retirement Systems?
YES
NO
EMPLOYMENT ELIGIBILITY (Please select ONE of the following)
I am a citizen or national of the United States
I am a lawful permanent resident (Alien # A)
I am an alien authorized to work until:
ETHNIC GROUP (Please select ONE of the following)
American Indian/Alaskan Native
Asian/Pacific Islander
Black (Non-Hispanic)
Hispanic
White (Non-Hispanic)
GENDER
Male
Female
CURRENT MILITARY STATUS (Please select ONE of the following)
None
Reserve
National Guard
MILITARY BRANCH:
Air Force
Army
Coast Guard
Marines
Navy
DO YOU HAVE VETERAN STATUS? YES
NO
EMERGENCY CONTACT #1
Information noted with an * is required
(
)
* Name:
* Relationship to you:
Address:
City/State/Zip:
* Home Phone #:
Work Phone #:
EMERGENCY CONTACT #2 (Optional - You may list a second Emergency Contact person)
* Name:
* Relationship to you:
Address:
City/State/Zip:
* Home Phone #:
Work Phone #:
THANK YOU!
Revised 9-2011
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Parent category: Business