Nevada System Of Higher Education Personal Data Form
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1NEVADA SYSTEM OF HIGHER EDUCATION PERSONAL DATA FORM
Campus
DRI GBC
NSHE
TMCC
UNR WNC
Action
New Employee Address Change*
Name Change**
Mail Stop Change
Other Effective Date ______________
Classified
Temporary
Technical
Employee ID # (if assigned)
Employee
Faculty
Postdoctoral Scholar
Graduate Assistant
Type
Letter of Appointment
Medical Resident
Volunteer/Adjunct
_________________________________
* This form is for human resources and payroll records only. Additional forms are required for insurance /retirement purposes. Contact your human resources office to obtain those forms.
**For name changes a copy of a new Social Security Card, W‐4, insurance change form, and retirement membership change form must be provided to the respective HR Office/Payroll.
EMPLOYEE PERSONAL CONTACT INFORMATION
Last
First
MI
Employee Name
If changing name, indicate former name here
Nickname
Street
City, State
Zip
Mailing Address*
Phone and Email
Phone
Email
Name
Relationship
Phone
Emergency Contact
*Mailing address is confidential with the exception that home address of all new or rehired employees is reported to the
State of Nevada Department of Employment, Training and Rehabilitation in accordance with NRS 606.120.
AFFIRMATIVE ACTION INFORMATION
By Federal mandate this institution collects and maintains the data below. Definitions:
Disability Status Not Disabled (F) Disabled Individual (T)
Gender
Female
Male
Date of Birth:
(mm/dd/yyyyy) _____/______/_____
Military Discharge Date: (mm/dd/yyyyy) _____/______/_____
Are you Hispanic or Latino?
Military Status: Check as many as apply or none.
A person of Cuban, Mexican, Puerto Rican, South or Central
Disabled Veteran
American or other Spanish culture or origin, regardless of race.
Other Protected Veteran (Campaign badge list)
Yes
No
See list
Armed Forces Service Medal Veteran
Racial Category or Categories: Please select the category(ies) with
which you most closely identify (check as many as apply or none).
American Indian or Alaska Native
Visa Status: Expiration Date(mm/dd/yyyy) ____/_____/______
Asian
Black or African American
Type ___________________________ (F‐1/J‐1/H‐1B )
Native Hawaiian or Other Pacific Islander
Country of Citizenship _________________________
White
EDUCATION INFORMATION
Degree
Month/Year
Major
Name of Institution
EMPLOYEE
SIGNATURE:
DATE:
WORK INFORMATION TO BE COMPLETED BY THE DEPARTMENT
Department
Mail Stop
Building
Phone
Fax
Room
Cell
Email
rev 4/20/09
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