Employee Data Sheet

							                        Bethel College Employee Data Sheet


The information collected in this form is treated as highly confidential. It is used for statistical
purposes and/or obtaining services in a medical emergency. Your cooperation in completing the data
is appreciated.

Name:
         (First)                    (Middle)               (Last)               (Preferred)
SSN:                                           Gender:                Birthday:
Address:                                                              Department:
City:                                                          State:                 Zip:
Bus Phone:                          Home Phone:                       Cell Phone:

Ethnic Backgound:                                          Veteran:
          White, Non-Hispanic                                    Yes                       No
          Black, Non-Hispanic
          Asian/Pacific Islander                           Military Reserve:
          American Indian or Alaskan Native                                         Active
          Hispanic                                                                  Inactive(Recall)
          Other (please specify)                                                    Inactive(No Recall)

Do you have a disability?             Yes                    No
If Yes, please note accommodations needed to perform essential duties of your position:


Martial Status:            Single                Married
       Spouse Name:                                            Date of Marriage(MM/DD/YY)
Spouse Date of Birth:                                              Spouse SSN:

Please list your dependent children below. Dependent Children for benefit purposes are defined as
your unmarried children from birth up until age 19 years old. The age 19 limit does not apply to a child
who is wholly dependent on you for support and maintenance or who is enrolled as a full-time student
and is less than 25 years of age.

   Dependent Name:                                            Dependent Name:
       Date of Birth:                                             Date of Birth:
               SSN:                                                       SSN:
       Relationship:                                              Relationship:

   Dependent Name:                                            Dependent Name:
       Date of Birth:                                             Date of Birth:
               SSN:                                                       SSN:
       Relationship:                                              Relationship:


Emergency Contact:                                                  Relationship:
      Home Phone:                                                   Work Phone:

The information I provided above is complete and true to the best of my knowledge. I understand that
it is my responsibility to notify the Human Resources Office of any changes.


Signature                                                              Date