UALR - Personnel Data Sheet


IMPORTANT: Your name must appear on this form EXACTLY as shown on your S.S.Card. An original S.S.Card must be presented with this form if you are a new hire or requesting name change.
Check Appropriate box
New Hire   Rehire   Change in Data   Name Change (Previous Name: )
Personal Information (Enter name exactly as it appears on your Social Security card):

Prefix     First Name     Middle Name     Last Name  
Suffix            Marital Status                Social Security Number   /   /  
Mailing Address Street or P.O Box Number    Apt/Lot#   
City    State   Zip Code   Home Phone  
Cell Phone   Current Email
Current UALR Employment Information:

Current UALR Work Assignment Job Title    Department/College
Hire Date    Work Telephone Number    Work Location
Academic Rank (if applicable)                                                                                                 
Biographic Information:

Gender    Female   Male   Date of Birth Are you a U.S Citizen?    Yes No  
If no, Country of Origin Visa Type    Visa Number  
Are you Hispanic/Latino Yes   No   What is your primary race?  
Please check any additional races that apply:      White    Asian    Black/African American    
American Indian/Alaskan Native   Native Hawaiian/Pacific Islander
Are you a veteran?
Yes   No   		If yes, please check all that apply
Special Disabled Veteran    Other Protected Veteran
Recently Separated    Armed Forces Service Medal Veteran  
Vietnam-Era   Veteran (Other than dishonorable discharge) 		Active duty
Separation Date:
Educational Information:

Indicate Highest Education Level Completed
  		University or College Granting Highest Degree
              
City and State
of University
Date Highest
Degree Awarded
Major Field of Study

Is your highest degree
considered terminal?
Yes   No  
Previous UALR/Arkansas State Agency Employment Information:

Have you ever worked full-time
for UALR or any Arkansas State
Agency? Yes   No   		If Yes,
When    Where 
Signature                                                                                     Date                                                  
                                           Please form before submitting