Personal Data Form
Department:
Campus: (Mark one)
O Briarcliff
O Midtown
Status: (Mark one)
O Full Time Faculty:
O Graduate Assistant:
O White Plains
O Downtown
O Pleasantville
O Part Time Faculty:
O Full Time Staff
O Student
O Part Time Staff
Last Name:
SSN:
First Name:
DOB:
Mailing Address:
City:
Permanent Address:
City:
Home Phone No.
Email Address:
MI:
State:
Zip:
State:
Zip:
Work Phone No.
Emergency Contact Name:
Relationship:
Phone No.
Personal Information
Gender:
Marital Status: (Mark one)
O Divorced
O Female
O Male
O Single
O Widowed
O Married
O Domestic Partner
O Separated
Are you Hispanic or Latino?
O Yes
O No
Select one or more of the following races (See Appendix A to choose from more specific races):
O American Indian or Alaska Native
O Native Hawaiian or
O Asian
O Black or African American
O White
Other Pacific Islander
Highest Level Education Completed
O High School Diploma/Equivalent
O Master’s Degree
O Associates’ Degree
O Ph.D.
Year Completed:
Major Field:
Employment Eligibility
Are you a U.S. Citizen?
If ‘No’, Visa Type
Expiration Date:
O Bachelor’s Degree
O Other Doctorate:
O YES
O F-1
O NO
O J-1
O H-1
O Other:
Alien Reg. #:
I certify that the information I have given is true and correct to the best of my knowledge.
Signature:
Date:
Appendix A
Hispanic - Caribbean
Hispanic - Central/South America
Hispanic - Mexican or Chicano
Hispanic - Other Spanish Origin
Native No, So, Central America
Native Alaskan
Native American
Other Tribal Affiliations
Asian - Chinese
Asian - Indian Subcontinent
Asian - Japanese
Asian - Korean
Asian - Taiwan
Other Asian or Far Eastener
Black - African
Black - African American
Black - Caribbean/West Indian
Other Black
Pacific Is - Guam
Pacific Is - Native Hawaiian
Pacific Is - Samoa
White - Arab/No. African/Middle E
White - European
Other White/Caucasian
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O