Employee Information Form

Information About Me
Information About My Position
Person ID Number: ______________________
(To be completed by PASC)
PUI D Number: _________-_________
Soc i al Security Num ber: ______________________
(Please provide Social Security Number for identification purposes if PUID is unavailable)
Name : __________________________________________________________
(Last) (First) (Middle Initial)
NAME CHANGE ONLY: _______________________________________________
This fiel d for NEW name chang e onl y. A ttach copi es of docu ment ation f or th e na me cha ng e.
(Examples include a Marriage License, Divorce Decree, Other)
Address: _________
(Street Address Line One)
_________
(Street Address Line Two)
_________
(City)
_________
(State)
_________
(Zip)
Telephone: ( ) -
Your home telephone and address m ay be published or shared unless you choose to
restrict this in formation.
Suppres s hom e phone & address
Date of Birth: _____/______/_______ (Month/Day/Year)
Gender:
Male
Female
Country of Birth: ________________________________________________
Country of Ci tizens hi p: ____________________________________________
(To be completed by Org Unit)
Pos iti on Num ber: _________________________
Organizati onal Uni t : _______________________
Building Abbreviation: ______________________
Work Location:
USA:
Foreign:___________________
Country
For those who do not have a building abbreviation,
pleas e l ist t he maili ng address :
Address: ______________________________
(Street Address Line One)
______________________________
(Street Address Line Two)
______________________________
(City)
______________________________
(State)
______________________________
(Zip)
Office Telephone: (_______) _______-________
Information About Prior Purdue Employment
If you have previously held a non-student position at Purdue,
please help us match our records by providing this information:
Employment
Sepa ration Date:
_____/_____/_______
Month Day Year
_____/_____/_______
Month Day Year
Name (if different than your current name):
___________________________________________
Education: Highest level completed. Addit i onal educ ation i nformation can be added via Employee Self Service.
Name of School
Date received
Degr e e /Diplom a
MM/DD/YYYY
Diploma or Degree
Major/Minor
Do you have relatives o n the Uni versit y Facul ty, S taff, or Board of Trustees?
No
Yes
(Relative’s Name and Relationship to You)
Criminal Conviction: An individual who has been convict ed of a c rime is not aut omatic al l y barred from empl oym ent.
Have you ever been convict ed of or pled guilt y to a crime? (Include court-mart i al convicti ons; exclude minor traff ic vi ol ations. )
No
Yes If yes, pleas e complet e the following:
Conviction
(e.g., felony, misdemeanor) Offense Convict i on Date Location (City, State) Court Action/Sent ence
The information I have provided to Purdue Univers ity, i ncludi ng, but not lim ited to, the information on my resume is t rue and com pl et e to the best of my
knowledge. P rovidi ng false or mi sleadi ng i nformation, or failing to provide mat eri al inform ation at any time during t
he employment proc ess may result in the
Universi t y t erminating my employm ent. Furthermore, if I am convicted of or plead guilt y to a crime af ter I complete this f orm, I will report the convicti on or
guilty plea to Human Resource Services and my Univers ity supervisor immediatel y.
Si gnature: ____________________________________________ Date: ______/ ______/_______
Form 13 (Revised April 2013)
Employee Informat ion Form
(please print)
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Employee Information Form PDF

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