Non-Student Non-Regular Temporary Employee Data Form

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Non-Student Non-Regular Temporary Employee Data Form
(Rev. 12/2013)
Employee Name ______________________________ TX ST ID/SSN _________________ Date of Birth ___________
Sex
Male
Female Home Phone (___ )__________________
Marital Status
Single
Married
Privacy on home address and phone number
Yes
No
Have you ever worked for the Texas Department of Criminal Justice or any State entity previously responsible for functions of TDCJ or
any of its divisions?
Yes
No
If yes, please mark “yes” for Privacy above.
Ethnicity/Race
Are you Hispanic or Latino? (
a person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or
Yes
No
origin, regardless of race)
Select the racial category or categories with which you most closely identify. Select as many as apply.
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Select the single race category with which you primarily identify. Select only one.
American Indian or Alaska Native
Asian or Pacific Islander
Hispanic or Latino
White, non-Hispanic
Black, non-Hispanic
U.S. Veteran
No
Yes
Vietnam Era
Disabled
% of Disablement _________
Veteran's employment preference, check if applicable:
(Individuals claiming preference must provide appropriate documentation.)
Veteran honorably discharged who served at least 90 consecutive days during a national emergency;
or less than 90 consecutive days and discharged due to a service-connected disability.
Surviving spouse (not remarried) of veteran killed while on active duty.
Child of veteran killed while on active duty.
Person(s) to contact in case of an emergency:
Name
Relationship
Phone
_________________________________________________________________________(
)______________________
_________________________________________________________________________(
)______________________
If you were working for the State of Texas on 8/31/95, have you left employment for more than 12 months?
No
Yes
N/A
Since 9/1/05, have you left State employment for more than 30 days?
No
Yes
If no to both, where/when did you work? ________
__________________
I am currently employed with another state agency or institution
No
Yes If yes, where?_____________________
(You must submit required multiple employment request forms to your Department Head for approval.)
I am currently employed in a benefits-eligible position with a community/junior college or independent school district
No
Yes If yes, where? _________________________________________________
I am a retiree with
TRS
ORP
ERS
None
Where did you retire from?______________________
_______________________
Retirement Date _____/__
___
/_____
Employee Acknowledgement:
I acknowledge that I have received these documents and understand that I am responsible
for reading all the information provided. I agree to comply with all Texas State University procedures, policies, and conditions of
employment. I understand that my department, or Human Resources will provide me with assistance should I have questions
concerning this information.
Multiple Employments with the State Notice
Political Aid and Legislative Influence Prohibited Notice
Campus Security
Immigration Reform and Control Act Notice
State Property Accounting and Responsibility Notice
Standards of Conduct Notice
Retaliation Prohibited by Law Notice
Drug Free Workplace Notice & Policy
Illegal Discrimination Notice
Notice of Workers Compensation Insurance & Network Requirements
I acknowledge being notified that, with exceptions, I have the right to be informed of and to receive, review, and, if necessary, correct the
information that Texas State University collects on me.
Employee Signature:_______________________________________
Date:________________________
Texas State University is a member of The Texas State University System.

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