Personal Data Form

Personal Data Form

* indicates required field

Select a contact:*

EMPLOYEE IDENTIFICATION

Bruin ID (if available):

Employee ID (if available):

Enter name exactly as it appears on your social security card or passport

First or Given Name:*

Middle Name:

Last or Family Name:*

Date of Birth:*

LOCAL/US MAILING ADDRESS

Street Address:*

City:*

State:*

Zip Code:*

Personal Contact Number:*

Email:*

EMPLOYMENT STATUS AND EDUCATION
Check the box if the statement applies to you.

I have an existing, concurrent appointment at UCLA or another UC.

I will be working outside of California or the U.S. remotely during my appointment (some or all of the time).

*Additional forms need to be completed.

If working remotely, from which state or country will you be working from?

I have a Work Study Award that I would like to apply to this appointment

Student Status:

Highest Degree Earned:

Year Awarded (Enter N/A if answered N to left):*

DISCLOSURES

Employee Organizations/Union Disclosures - Mark the information below that you DO NOT want to be released:

Home Address Personal Contact Number Email Address

UC Directory Disclosures - Mark the information below that you DO NOT want to be listed:

Home Address Personal Contact Number Spouse Name

SIGNATURE

Employee Electronic Signature (Type full name):*

Date Completed:*