Human Resources Employee Information Form

Human Resources
Your HR team for the system office
Employee Information Form
Current Date: _
DEMOGRAPHIC INFORMATION
Last Name: ______________________ First Name:____________________ Middle: __________________
Former Names: ______________________________________________________________________________
Date of Birth: _______________________
Social Security Number: _________________________
Home Address: ____________________________________________________________________________________
Apt/Unit: __________________ City: ________________ State: _______ Zip Code: __________
County: ___________________ Home phone: ________________ Mobile Phone: __________________
RACE AND ETHNIC BACKGROUND
Are you Hispanic or Latino?
Yes
No
Select One or More of the
following races:
African American or Black (A person having
origins in any of the black racial groups Africa)
Native Hawaiian or Other Pacific Islander (A person
Having origins in any of the original peoples of
Hawaii, Guam, Samoa or other Pacific Islands)
American Indian or Alaska Native (A person having
origins in any of the original peoples of the North and
South America, including Central America)
Asian (A person having origins in any of the original people
of the Far East, Southeast Asia or the Indian subcontinent)
Caucasian or White (A person having origins in any
Of the peoples of Europe, the Middle East or North Africa)
Marital Status:
Single Married Divorced Separated
Widowed
Effective Date of Current Marital Status: _________________________
Gender: Female Male US Citizen: Yes No Veteran: Yes No

Disability Status: Yes No If yes, please provide a brief description
A disability may be defined as:
a) having a physical and/or mental impairment
Which substantially limits one or more major
Life activities;
b) having a record of such impairment; or
c) being regarded as having such an impairment.
“Major life activities” means functions such as caring for one’s
self, performing manual tasks, walking, seeing, hearing, speaking,
breathing, learning and working.
ADDITIONAL EMPLOYMENT INFORMATION
Have you previously been employed by the State of Minnesota? Yes No
If yes, please indicate which agency or agencies and dates of employment:
If you were previously employed by the State of Minnesota, which retirement plan were you in? (i.e. MSRS, TRA, etc.)
Educational Background (Report all earned degrees and provide copies of official transcript for each.)
Institution #1:__________________ Institution #2: __________________ Institution #3: ___________________
City & State: __________________ City & State: __________________ City & State: ___________________
Degree: __________________ Degree: __________________ Degree: ___________________
Date Rec’d: __________________ Date Rec’d: __________________ Date Rec’d: ___________________
Emergency Contact Information:
Name (1): ______________________________ Name (2): _______________________________
Address: ______________________________ Address: _______________________________
State/Province: ______________________________
State Province: _______________________________
Zip Code: ______________________________ Zip Code: _______________________________
Home Phone: ______________________________ Home Phone: _______________________________
Relationship: ______________________________ Relationship: _______________________________
I hereby declare that the information provided on this form is true and accurate to the best of my knowledge.
Employee Signature
_________________________________________________