PERSONNEL FILE INFORMATION

FIRST NAME:       LAST NAME: 

HOME PHONE: 

ADDRESS:    CITY:     STATE: 

DEPARTMENT:    Custodial    Heating Plant     Campus Services     Grounds

BANNER NUMBER:    See Secretary if you do not have your Banner ID Number.

DRIVER'S LICENSE NUMBER:                  STATE: 

DATE OF BIRTH: 

DOCTOR'S NAME:                                      PHONE: 

BLOOD TYPE: 

ALLERGIES: 

                 PERSON(S) TO NOTIFY IN AN EMERGENCY

SPOUSE:                       PHONE: 

PARENT:                      PHONE: 

                ALTERNATE PERSON TO NOTIFY

 NAME:                        PHONE: 

DATE HIRED: 

This information is kept in strict confidence to be used in an emergency should you be injured on the job.

I, the undersigned, will allow Campus Services Staff to release this information when or if it is needed.

Signature _________________________________________            Date ________________________