PERSONAL DATA SHEET
This form is to be completed by all new employees. Current employees must complete the appropriate
section(s) on this form when a change to any of the information has occurred.
All information is kept confidential and separate from your personnel file.
Name: _____________________________________________________________
Male
Female
Date of Birth: __________________
Address: __________________________________________________________
Phone: home (______) ______________________________
__________________________________________________________________
cell
(______) _______________________________
Single
Email Address: ____________________________________________________
Married
Divorced
Widowed
Social Security # if new hire: _________________________________________
LID # required if current employee: ____________________
Position: ___________________________________________________________
Department: ________________________________________
EMERGENCY INFORMATION
Contact
Relationship
Name: __________________________________________
Spouse
Grandparent
Ex-spouse
Sister/Brother
Phone: home (______) ____________________________
Child
Aunt/Uncle
cell
(______) ____________________________
Step-child
Cousin
work (______) ____________________________
Parent
Parent-in-law
Step-parent
Friend/Other___________________________
Relationship
Alternate
Relationship
Name: __________________________________________
Spouse
Grandparent
Ex-spouse
Sister/Brother
Phone: home (______) ____________________________
Child
Aunt/Uncle
cell
(______) ____________________________
Step-child
Cousin
work (______) ____________________________
Parent
Parent-in-law
Step-parent
Friend/Other___________________________
Relationship
FEDERAL REPORTING REQUIRES THIS INFORMATION
It is the policy of Lakeland Community College to provide equal
Are you Hispanic or Latino?
employment opportunity to all employees and applicants for
Yes
employment without regard to race, color, national origin or ancestry,
No
sex, sexual orientation, marital and or parental status, age, religion
disability or veteran status. Various agencies of the United States
Race / Ethnicity (Please select one or more):
government require employers to collect information. This information
American Indian or Alaskan Native
Asian
is for purposes of compliance with record-keeping requirements and to
Black or African-American
determine recruiting and employment patterns and in no way affects
eligibility for promotions, transfers, etc.
Native Hawaiian or Pacific Islander
White
Do you consider yourself an individual with a disability?
No
Yes
Type of Disability: __________________________________________________________________________
Please sign to verify that the information you have provided is accurate to the best of your knowledge.
________________________________________________
_________________________________
Signature
Date
s:\HR Forms – Tax Packet\Personal Data Sheet 7-2010.docx