PERSONAL DATA FORM (PDF-07/05/02)

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					                                                                                                    UCLA Healthcare


                                       PERSONAL DATA SHEET
                                                   (Rev. 0305/04)


                                Please complete the information listed below
                                          Personal Information
NOTE: Employee name entered in the Employee Data Base ( EDB) must be identical to the name as it
appears on the social security card.
Employee Name: ________________________________________________________________________
                  Last,                    First                      Middle Initial     Suffix

Date of Birth: ____/___/____         Social Security Number: _______/_____/_______

Mailing Address: _________________________________________________________________________

______________________________                     _________                      ______________
City                                               State                          Zip Code

Home Phone Number: ______ /______/________                  Spouse Name: _____________________

Foreign Address: ________________________________________________________________________

__________________________                        _____________________
Country                                           Postal Code
UC Directory Disclosures: (Circle information that you DO NOT want listed: Home Address/Home Phone/Spouse
Release to Employee Organizations: (Circle information that you DO NOT want listed: Home Address/HomePhone

UC Directory Disclosures: (Circle information that you DO NOT want listed: Home Address/Home Phone/Spouse
 UC Student Status                     Highest Degree Completed            US Citizenship/VISA Status
Release to Employee Organizations: (Circle information that you DO NOT want listed: Home Address/HomePhone
Phone/Spouse
  Not Registered                       High School                         Yes
    Graduate*                         Trade Certificate                    No (if no, complete
    Undergraduate*                    Associate                               Info below
    Not Regis. Degree Candidate       Bachelor                            VISA Type: _________
    Other UC Campus
                                       Master                              VISA/WORK PERMIT END
 *Number of units:________             Doctorate                           DATE:_____/____/______

                                      Year Awarded:_________
                   Prior University and/or State of California Employment Service

 Have you ever worked for the University of California? Yes: _____ (if yes, provide related info below) No: __
 Campus: ___________________ Department(s): ______________________________________________
 Periods of Employment:
 ______________________________________________________________________________________

 Have you ever worked for the State of California? Yes: ____ (if yes, provide related info below) No: _______
 Employer: ____________________          Periods of Employment:__________________________________

 Employee must obtain and provide written verification and confirmation of prior State of California employment
 service.


 Reviewed by:_______________________________________ Date:______/______/_______
 Date of EDB entry: ______/_______/__________

				
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