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Employee Demographic Information

NetID

PID

Legal Name and Address:

Date of Birth:*

Name:*

Personal E-mail Address:*

Social Security Number:*

Phone:*

Preferred Pronouns:

Address 1:*

Address 2:

State:*

Employment State:

City:*

Gender:

Zipcode:*

Are you a former or current CSU-Pueblo Student?*

Emergency Contact Information:

Relationship:

Name:

If Married, please provide Spouse's Name:

Phone:

Ethnicity and Race:

Please note: disclosure of ethnicity and race information is voluntary and responses will not be used in a discriminatory manner.

Ethnicity (Please select one)

Hispanic/Latino, Chicano, Cuban, Puerto Rican, Mexican American

Non-Hispanic/Latino

Race (Regardless of answer above, select all that apply to you)

Native American/Indigenous

Asian (Japanese, Chinese, Vietnamese, Korean, Filipino, Indian, etc)

Black or African American (Including Africa and Caribbean descendants)

Native Hawaiian/Indigenous Pacific Islander

White, Anglo, Caucasian (Includes the Middle East, Persia)

Employees Military Status:

Yes No

SELECTION REQUIRED

Have you ever been in the military?

If yes, please complete the following.

Veteran National Guard Active Reserve Inactive Reserve Retired

From Date:

To Date:

Citizenship:

SELECTION REQUIRED

Yes No

Are you a United States Citizen?*

If no, please complete the following.

Visa Expiration Date:

Visa Type:

Country:

Education:

Education Level:

If Other - Please Describe:

Enter Exact Type of Highest Degree:

Year of Completion:

Hire Information and Signature:

Department Name:

Supervisor/Sponsor:*

Job Assignment:

Type of Employee:

Date of Hire:

Supervisor Email*

By typing my name in the box below, I confirm that the above information is true and accurate to the best of my knowledge.*

I confirm

REQUIRED

Date*

Employee's Signature:*

Save Draft

Draft name: