Employee Personal Information Record Form
*=Required Field
Date* (mm/dd/yyyy)
Soc Sec No* (xxx-xx-xxxx)
Primary Campus*
Elsah
St. Louis
Last Name* (Legal)
First Name* (Legal)
Middle Name (Legal)
Prefix*
Miss
Ms.
Mr.
Mrs.
Dr.
Preferred Name
Date of Birth* (mm/dd/yyyy)
Gender*
Male
Female
Marital Status*
Married
Single
Military Status
Primary Residence Address*
Do you reside in the
City of St. Louis
?*
(For tax purposes only.)
Yes
No
Primary Residence Telephone*
(xxx-xxx-xxxx)
Mailing Address (if different)
Secondary Residence Address
Secondary Residence Telephone
(xxx-xxx-xxxx)
Cell Phone Number
(xxx-xxx-xxxx)
Ethnicity*
White, non Hispanic
Black, non Hispanic
Hispanic
Asian or Pacific Islander
Native American or Alaskan native
Unspecified
Citizenship*
Emergency Contact Name*
Emergency Contact Relationship*
Emergency Contact Phone No*
(xxx-xxx-xxxx)
Spouse Name
Spouse Soc Sec No (xxx-xx-xxxx)
Spouse DOB (mm/dd/yyyy)
Please list children (all ages)
First Child Name
First Child Soc Sec No
(xxx-xx-xxxx)
First Child DOB (mm/dd/yyyy)
Second Child Name
Second Child Soc Sec No
(xxx-xx-xxxx)
Second Child DOB (mm/dd/yyyy)
Third Child Name
Third Child Soc Sec No
Third Child DOB (mm/dd/yyyy)
Fourth Child Name
Fourth Child Soc Sec No
Fourth Child DOB (mm/dd/yyyy)
Fifth Child Name
Fifth Child Soc Sec No
Fifth Child DOB (mm/dd/yyyy)
