HomeMy WebLinkAboutDemographic Form
Instructions:
1. Please complete the Part 1 thru 6.
Department of Human Resources
New Hire Employee Demographic Data Form
2. Forward the completed form to the HR department for processing.
Part 1 Employee Identification
Employee’s Name (Last Name, First Name, MI) as they appear on your Social Security Card. For
Name Changes use the Status Change Form.
Prefix:
Mr. Dr.
Ms . Miss.
Mrs.
Suffix:
II Sr.
III
Jr.
BCC Colleague ID#: Social Security Number:
Part 2 Employee Contact Information
Permanent Address: City/County: State/Zip:
Mailing Address (if different): City/County: State/Zip:
Phone: Cell Phone: Fax:
Email Address: Employment Status:
Part Time (Temp/Perm) Full Time
Part 3 Affirmative Action Information
Gender:
Male Female
Marital Status:
Single Married Div orc ed Widowed
Legally Separated Domes tic Partner / Civil Union
Employee’s Birth Date (MM/DD/YY):
Please indicate your permission to share your birthday month and
day on our Bergen Community College announcements.
Y es No
Ethnic code:
His panic or Latino A meric an Indian or A laskan Native
A s ian Blac k or African A merican White
Nativ e Hawaiian or other Pac if ic Is lander
Citizenship Status:
Birth Country:
US Citiz en Birth (Nativ e) US Citiz en Naturaliz ed
Permanent Res ident Non Res ident A lien
Visa Type: Exp. Date:
Military Status :
V eteran Non-Veteran
Disability (Optional):
None Learning Blind Mobility Multiple Impairments Other
Have you ever applied or
attended BCC as a student?
Y es No
Are you now or have you ever been employed by a New Jersey State Agency or State college/university of
New Jersey?
Yes No
Retired Public Employee:
Are you a retiree of any public employer in the
State of New Jersey?
Y es No If yes, Name of Agency / Institution:
Start Dt. (MM/DD/YYYY) End Dt. (MM/DD/YYYY)
Part 4 Education (list the highest diploma/degree you have attained)
Diploma/Degree: Year Earned: Major
School, University or College: School Address (City, State, Country):
Part 5 Emergency Contact
Contact Name (Last, First): Contact Phone Number: Relationship to Employee:
Part 6 Certification
I certify the information, which I have provided, is complete and accurate to the best of my knowledge.
Employee Signature: Date:
Rev. 07/2014 www.bergen.edu