DUKE UNIVERSITY by G4SUK622

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									                                    DUKE UNIVERSITY
                   Biographical Data Sheet for Faculty, Staff and Support Staff
Date: _____________________              Duke Unique ID: _________________________

Last Name: _______________________ First Name: ___________________________ MI: ______

Birthdate: ___________________E-mail Address: ___________________________________________

Home/Permanent Address: ____________________________________________________

      City: _______________ State: ______ Zip: ________ Area Code/Phone: __________________

Campus/Temporary Address: __________________________________________________

      City: _______________ State: ______ Zip: ________ Area Code/Phone: __________________

Name of Emergency Contact: __________________________ Area Code/Phone: __________________

Marital Status: ______________ Sex (M / F)*: ________ Race*: _______________________

U.S. Citizen (Y / N): _______ Handicapped (Y / N): _________

Veteran (Y / N): _______ Vietnam Veteran (Y / N): _______ Disabled Veteran (Y / N): ________

Have you Worked at Duke Before (Y / N): ________

      If Yes, Dates Employed: ________________________ Departments: _________________________

EDUCATION:      Highest Grade Completed? _______________

Degree(s) Earned or Matriculation / Dates / Institution:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Honors (Including Honorary Degrees) / Dates / Institution:
__________________________________________________________________________________________
__________________________________________________________________________________________

Previous Professional Experience: Position / Dates / Institution
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Licensed Professional Practice and Professional Certification / Dates: _________________________________
__________________________________________________________________________________________

*Required for Equal Employment Opportunity Purposes Only

								
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