File Name: New Employee Information Form.pdf

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Summary

New Employee Information Form
Employee’s Name: Social Security No: Date of Birth: Gender:
Address: Telephone No.:
Name of Emergency Contact: Relationship: Telephone No:
Address:
3. MARITAL STATUS: Single Married
4. Veteran Status: Non-veteran Special Disabled Veteran Vietnam-era Veteran
Disabled Veteran Other Protected Veteran Recently separated Veteran
Armed Forces Service Medal Veteran Discharge Date (if claiming veteran status) _____________
5. DO YOU HAVE PREVIOUS/CURRENT COMMONWEALTH OF PENNSYLVANIA
SERVICE (PA STATE SYSTEM UNIVERSITIES, STATE AGENCIES, PUBLIC
SCHOOL SYSTEM)?
Yes No
IF YES DID YOU PARTICIPATE IN A RETIREMENT PLAN?
Yes No
IF YOU ANSWERED YES CHECK FROM THE LIST BELOW WHICH PLAN
YOU PARTICIPATED IN:
State Employees Retirement System Public School Employees Retirement System
TIAA-CREF Fidelity
____________________________________ _______________
Employee Signature Date
1
1. What is your Ethnicity? (Select One Option):
Hispanic or Latino
Persons of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or
origin, regardless of race

Not Hispanic or Latino
2. What is your Race? (Select One or More):
American Indian or Alaska Native
Persons having origins in any of the original peoples of North and South America (including
Central America)

Asian
Persons having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian
subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the
Philippine Islands, Thailand, and Vietnam

Black or African American
Persons having origins in any of the black racial groups of Africa

Native Hawaiian or Pacific Islander
Persons having origins in any of the original peoples of Hawaii, Guam, Samoa, or other
Pacific islands

White/Caucasian
Persons having origins in any of the original peoples of Europe, the Middle East, or North
Africa

____________________________________ _______________
Employee Signature (Please Print & Sign) Date
2

New Employee Information Form Employee’s Name: Social Security No: Date of Birth: Gender: Address: Telephone No.: Name of Emergency Contact: Relationship: Telephone No: Address: …