New Employee Information Form printable pdf download

THIS IS A STUDENT EMPLOYEE:

Mail form to: STUDENT EMPLOYMENT Box 407810 Station B.

Deliver form to: 2309 West End Ave, Nashville TN 37203

New Employee Information Form

(

)

Employee ID or Social Security Number

Home Phone Number

Date of Birth

Last Name

First Name

M.I.

Home Mailing Address

City

State

ZIP

GENDER:  Male

 Female

 I do not wish to disclose

MARRIED:

 Yes

 No

Race/Ethnic Group

Are you Hispanic or Latino? (Check the appropriate box)

 Yes

A person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or

 No

origin, regardless of race

Please select one or more races from the list below. (Check all that apply)

 White

A person having origins in any of the original peoples of Europe, North Africa, or the Middle East

 Black or African American

A person having origins in any of the Black racial groups of Africa

 American Indian/Alaskan Native

A person having origins in any of the original peoples of North, Central or South America and (not

Hispanic or Latino) who maintains tribal affiliation or community attachment

 Asian

A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian

Subcontinent. This area includes China, Japan, Korea, Thailand, and Vietnam.

 Pacific Islander

A person having origins in any of the original peoples of the Pacific Islands, the Philippine Islands,

Samoa, Hawaii, and Guam.

 I do not wish to disclose

Military Information

(Check all that apply)

 Not applicable

 Disabled Veteran

a veteran 1) of the U.S. military ground, naval or air service who is entitled to compensation (or who but for the receipt of

military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs, or

2) who was discharged or released from active duty because of a service‐connected disability

 Vietnam‐Era Veteran

a veteran whose active military, naval or air service was during the period August 5, 1964 through May 7, 1975 who served

on active duty for more than 180 days and was discharged with other than a dishonorable discharge or because of a

service‐connected disability

 Other Protected Veteran

a veteran who served on active duty in the U.S. military ground, naval or air service during a war or in a campaign or

expedition for which a campaign badge has been authorized, under the laws administered by the Department of Defense

 Armed Forces Service

a veteran who, while serving on active duty in the U.S. military ground, naval or air service participated in a U.S.

Medal Veteran

military operation for which an Armed Forces Service Medal was awarded pursuant to Executive Order 12985 (61 FR

1209, 3 CFR, 1996 Comp., p. 159)

 Recently Separated Veteran

a veteran during the three‐year period beginning on the date of such veteran’s discharge or release from active duty in

the U.S. military ground, naval or air service

Military Status:

 Active Reserve

 Inactive Reserve

Separation Date

Processing Office Use Only

Vanderbilt is committed to principles of equal opportunity and affirmative action. Vanderbilt is committed to a policy of

non‐discrimination in employment and education and complies with the requirements of the Americans with Disabilities

Pay Group

Act of 1990 (ADA) and the Rehabilitation Act of 1973, which prohibit discrimination against persons with disabilities. If

you have questions or concerns pertaining to accommodation services for people with disabilities contact the Disability

Employee ID #

Program Director, Opportunity Development Center, VU Station B #351809, 2301 Vanderbilt Place, Nashville, TN

37235‐1809; phone 615.322.4705 (V/TDD); fax 615.343.0671; Web site

Entered by

Audited by

Signature

Date

Date Received in Processing

7/10

New Employee Information Form

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