Personal/biographic Data Form Page 2
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1
2TEXAS TECH PERSONAL/BIOGRAPHIC DATA FORM, CON’T
Highest Level Education Information
Institution_________________________________________________
City______________________________
Diploma or Degree/Major_____________________________________
Graduation Date____________________
Institution_________________________________________________
City______________________________
Diploma or Degree/Major____________________________________
Graduation Date____________________
PPAGENL
I have been a Peace Officer, Security Officer or Texas Department of Criminal Justice employee in the State of Texas
Yes
No
WOAHOLD
Texas Employee Confidentiality Indicators
:
The Public Information Act allows employees, public officials, and former employees to
elect whether to keep certain information about them confidential. Unless you choose to keep it confidential, the following information about you
may be subject to public release if requested under the Texas Public Information Act.
Please indicate whether you wish to allow public release of the following information:
Social Security Number
Yes
No
Home Address
Yes
No
Emergency Contact Information Yes
No
Home Telephone Number Yes
No
Information that reveals whether you have family members Yes
No
PEAEMPL
Please complete if you have previous service with a state agency in Texas.
Prior state service may affect your eligibility for Longevity Pay, Vacation accrual rate, Optional Retirement Program,
and other benefits depending upon the circumstances. List the State Agencies at which you were employed below.
Include prior Texas Tech University/Texas Tech University Health Sciences Center service. Give name under which
you were employed at each institution or agency if not the same as above.
Agency & Address
From Mo/Yr
To Mo/Yr
Position title
Name (if different)
____________________________
____________ ___________ ________________
_________________
____________________________
____________ ___________ ________________
_________________
____________________________
____________ ___________ ________________
_________________
PEAEMPL
I certify that the information contained on this form is true and correct to the best of my knowledge and ability.
Name _________________________________________________________Date ________________________
Revised 9.1.2012
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