PE R SO N A L DA T A FO R M 
GENERAL INFORMATIONPrefix 
Last Name 
First Name 
Middle Name 
CONTACT INFORMATIONNumber, Street Apt# 
City 
ZipState Code 
( ) ( ) 
Home Telephone # Work Telephone # 
PERSONAL INFORMATIONSocial Security Number 
Gender: Female Male 
Date of Birth 
ETHNICITY 
Please check the category that is most appropriate to your background.* 
White (not Hispanic) 
Black (not Hispanic) 
Hispanic (of any race) 
Puerto Rican 
Asian 
American Indian or Alaskan Native 
Italian American 
MARITAL STATUSMarried 
Single 
Divorced 
Legally Separated 
Widowed 
CITIZENSHIP STATUS 
U.S. Citizen Yes No 
If No: Country of Origin 
Resident Alien Non-Resident Alien 
Have you clearance to work in the U.S.? Yes No 
Type of Visa 
Primary purpose in the U.S. 
Intended length of stay 
VETERAN STATUSVeteran – other than Vietnam 
Veteran – Vietnam 
No Service 
EMERGENCY CONTACT 1Name 
Address 
StateCity Zip 
( ) ( ) 
Home Telephone # Work Telephone # 
EMERGENCY CONTACT 2Name 
Address 
StateCity Zip 
( ) ( ) 
Home Telephone # Work Telephone # 
EDUCATIONAL DATA 
Highest Educational Level: (Attach proof of degree) 
High School Diploma or Equivalence 
Associate Degree 
Bachelors Degree 
Masters Degree 
Doctorate 
Employee Signature 
Date 
Dept Job Start Date 

*We are required by law to monitor our Affirmative Action Program, and to collect ethnic data on all employees under Federal Executive Order #11246. Submission of this 
information is voluntary. 


(Prefix) 
(City) 
(Code) 
(Area_Code_2) 
(Work_Telephone) 
(radiobutton) Unchecked
(radiobutton) Unchecked
(Gender) Unchecked
(radiobutton) Unchecked
(radiobutton) Unchecked
(radiobutton) Unchecked
(radiobutton) Unchecked
(Have you clearance to work in the U.S) Unchecked
(Type of Visa) 
(Primary purpose in the U.S) 
(radiobutton) Unchecked
(radiobutton) Unchecked
(radiobutton) Unchecked
(Intended length of stay) 
(Name) 
(Name) 
(undefined) 
(Address) 
(Address) 
(Emergency_Contact_State_2) 
(Emergency_Contact_Zip_2) 
(Ctiy) 
(radiobutton) Unchecked
(radiobutton) Unchecked
(Date) 
(radiobutton) Unchecked
(radiobutton) Unchecked
(Emergency_Contact_Home_Telephone_Area_Code_2) 
(Job Start Date) 
(Dept) 
(Emergency_Contact_Home_Telephone_2) 
(Emergency_Contact_Work_Number_Area_Code_2) 
(Emergency_Contact_Work_Number_2) 
(Emergency_Contact_Area_Code_1) 
(Emergency_Contact_Home_Telephone_1) 
(Emergency_Contact_Work_Number_Area_Code_1) 
(Emergency_Contact_Work_Telephone_1) 
(State) 
(Zip) 
(Have you clearance to work in the U.S) Unchecked
(radiobutton) Unchecked
(radiobutton) Unchecked
(radiobutton) Unchecked
(U.S. Citizen) Unchecked
(U.S. Citizen) Unchecked
(If No: Country of Origin) 
(radiobutton) Unchecked
(radiobutton) Unchecked
(radiobutton) Unchecked
(radiobutton) Unchecked
(radiobutton) Unchecked
(Date of Birth) 
(Gender) Unchecked
(Social Security Number) 
(Area_Code_1) 
(Home_Telephone) 
(State) 
(Apt#) 
(Number, Street) 
(Last Name) 
(First Name) 
(Middle Name) 
(radiobutton) Unchecked

Instructions for POIs 

1) Complete attached PDF form 
2) Print form 
3) Then mail/hand-in to Human Resources SH-230 or Fax it to (718) 960-1191 

You will be contacted when your information has been successfully entered into 
CUNYfirst.