California State University, Northridge State & Auxiliary Employee Information Form
Employer: Job Title: Change Effective Date: State The Univ. Corp Associated Students Univ. Student Union Department: Full Legal Name (Last Name) City Gender: (First Name) New Employee Change/Correct Information
CSUN ID #:
(If this is a Name Change) Former Name: Supervisor: (M. I.) State Date of Birth: Prefix Miss Zip Social Security Number: Mr. Mrs. Ms. Dr.
Mailing Address: (Number, Street Name & Apt. #) Home Phone: Other Phone Number:
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USA Visa Permit
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Perm Resident (B) Type
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F
(C) Doc Number (D) Exp. Date
Citizenship:
Other (If you are NOT a citizen of the U.S., please complete A, B, C, & D)
(A) E-mail Address
ETHNIC BACKGROUND: Compliance with this request is consistent with U.S. Department of Labor regulations mandated by Federal Executive Orders 11246 and 11375.
This is confidential information and is not used in making personnel decisions. The University is obligated to make visual ethnic identification of individuals who do not complete this item. Enter the most appropriate letter from the list below:
A. B. C. D. E.
Mexican, Mexican-American/Chicano Puerto Rican Cuban Other Latino/Hispanic White (Not Hispanic)
F. Black (Not Hispanic) G. Filipino H. American Indian I. Japanese J. Chinese Disability? Yes* No
K. Korean L. Vietnamese M. Asian Indian N. Eskimo O. Aleut
P. Q. R. S. T.
Hawaiian Samoan Guamanian/Chomorron Other Asian Other Pacific Islander
U. Cambodian V. Laotian Z. Decline to state
Vietnam Era Vet? Yes* No
Disabled Veteran? Yes* No
Have you been employed by another California State Agency/Campus or Public Agency? Yes No S– E– K– J–
If Yes to any of the three questions, please enter letter from Employee Veteran/Disability Status Survey form attached: If Yes, indicate name of employer: Last Name (if different): Separation Date:
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HIGHEST EDUCATION LEVEL COMPLETED -- Enter the most appropriate letter from list below: Some elementary school I – Some high school B – * Bachelor’s degree P – * Professional degree Completed elementary school H – Completed high school or G.E.D. M – * Master’s degree C – * Professional certificate Some junior high school Q – Some college D – * Doctorate T – * Trade or craft certificate Completed junior high school A – * Associated Arts degree * School Code (FICE Identification Code) – Refer to the Higher Education Directory located in the Sign-In Area School Code* Degree Year Earned Name of School Major
EMERGENCY CONTACT (Last Name, First Name, Middle Name) Address: (Number, Street Name, Apt #, City, State and Zip Code)
Relationship
Home Phone Number
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Alternate Phone Number
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Phone Type
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PAYROLL DESIGNEE: I hereby designate the following person, who is over age 18, to receive my paycheck(s) in the event that I am unable to do so. This designation will remain in effect during my employment or until revoked by me in writing. Designee’s Name: (Last Name, First Name, Middle Initial) Relationship Home Phone Number Alternate Phone Number
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Address: (Number, Street Name, Apt #, City, State and Zip Code)
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I affirm that all the answers and statements on this form are complete and true to the best of my knowledge and belief.
Employee Signature Date
State Employee Only – OATH OF ALLEGIANCE (U.S. Citizens Only)
I, , do solemnly swear (or affirm) that I will support and defend the Constitution of the United States and the Constitution of the State of California against all enemies, foreign and domestic; that I will bear true faith and allegiance to the Constitution of the United States and the Constitution of the State of California; that I take this obligation freely, without any mental reservation or purpose of evasion; and that I will well and faithfully discharge the duties upon which I am about to enter.
Employee Signature
FOR HR USE ONLY License/Certification Required? Yes No (If yes, answer A, B & C) (A) License Type (B) State (C) Exp. Date Fingerprinting Required? Yes No
AUTHORIZED PERSONNEL SIGNATURE This form was completed (and Oath subscribed before me) on __________________
Date OHRS 30-72 (Revised 01/2007)
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Signature
Distribution -- Original: Employee Personnel File; Copies: Employee, Payroll/HR, System