APPOINTMENT CHECKLIST
HUMAN RESOURCES CORE DATA INTAKE FORM
PCN:__________________________ CERT:_________________________ EMP#________________________
EFFECTIVE DATE OF HIRE: _______/_______/_______
NAME: FIRST:________________________ MIDDLE:_________________ LAST:____________________________________
HOME STREET ADDRESS: ________________________________________________________________________________
CITY: ______________________________________________________
STATE: _____________________________________________________ ZIP CODE: ___________________________________
HOME PHONE (with area code): ________________________ CELL PHONE (with area code): ________________________
GENDER: CHECK ONE __________ MALE _________ FEMALE
DEGREE TYPE: CIRCLE ONE ONLY:
B - LESS THAN HIGH SCHOOL C - HIGH SCHOOL OR EQUIVALENT D - SOME COLLEGE
E - TECHNCIAL SCHOOLF - 2 YEAR COLLEGE DEGREE G - BACHELOR’S LEVEL H - SOME GRADUATE SCHOOL
I - MASTERS LEVEL J - DOCTORATE (ACADEMIC) K - DOCTORATE ( PROFESSIONAL)
LANGUAGE: PRIMARY: (I.E. ENGLISH) _________________ SECONDARY (I.E. SPANISH): ______________________
MARITAL STATUS: ____________________ DATE OF MARRIAGE: ______________________
MILITARY STATUS: CIRCLE ONE: A: NONE B: RESERVE C: WAR SERVICE - SPECIFY BELOW:
WAR SERVICE DATES: BEGIN DATE: ____________________ END DATE: ______________________
DATE OF BIRTH: MONTH: ____________DAY_________ YEAR ____________
BIRTH COUNTRY (I.E. USA, FRANCE, ETC.) __________________ U.S. CITIZEN____YES ____NO -SPECIFY BELOW
BIRTH STATE __________________ BIRTH CITY ______________________SSN # __________- ________ - ___________
ETHNIC GROUP: CIRCLE ONE ONLY
A: AMERICAN INDIAN/ALASKAN NATIVE B: ASIAN/PACIFIC ISLANDER C: BLACK D: HISPANIC E: WHITE
EEO GROUP: CIRCLE ONE ONLY
A: ALASKAN NATIVE B: AMERICAN INDIAN C: BLACK D: CHINESE E: EASTERN INDIA F: JAPANESE
G: MEXICAN H: NONE I: OTHER HISPANIC J: PACIFIC ISLANDER K: PUERTO RICAN J: WHITE
PRIMARY EMERGENCY CONTACT INFORMATION:
CONTACT NAME: _________________________________
RELATIONSHIP TO EMPLOYEE: _______________________________
CONTACT STREET ADDRESS: _________________________________________________________
CITY: ______________________________
STATE: ____________________________ ZIP CODE: ___________________________
CONTACT PHONE NUMBERS WITH AREA CODE: ____________________________________________________________
8.2.13 bt
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