Duke University/Health System Instructions: The following information is required to process your employment at Duke. Please complete the form by entering a response in each field. If using a computer, tab to the next entry. A resume may be attached to this form in lieu of completing the section on Campus address information may be completed by the department. “Education/Experience.” After completing this form, print and sign. If you have a disability and would like to explore reasonable accommodations, please contact the Office for Disability Management Systems at 919-668-6213. TTY 919-668-1329 PERSONAL DATA (Printed or Typed Only) Last Name: First Name: M.I.: (Family Name) (Given Name) Known as: Date: Gender* Male Female (Preferred Name) Ethnicity* (select one) Protected Veteran Self-Identification Voluntary Self-Identification Registered Duke Hispanic/Latino I identify as one or more of these of Disability Student Non-Hispanic/Latino classifications: Yes, I have a disability (or N/A Race* (select all that apply) Disabled Veteran previously had a disability) Undergraduate American Indian or Alaskan Recently Separated Veteran No, I don’t have a disability Freshman Native Active Duty Wartime or Campaign I don’t wish to answer Sophomore Asian Badge Veteran Junior Black or African American Forces Service Medal Veteran Citizenship Senior Native Hawaiian or Other I am a protected veteran, but choose US Citizen Graduate/Professional Pacific Islander not to self-identify the classification Lawful Permanent Resident Grad/Prof White I am NOT a protected veteran Non-Resident (INS) Marital Status Single Married U.S. Home Address Campus Address (if known) Address line 1: Address line 1: (Bldg. & Room Number of Physical Work Location) Address line 2: Address line 2: (P.O. Box Number) City: City: State: Zip: State: Zip: Telephone: Telephone: Person to be notified in case of emergency: Telephone numbers (provide all that apply) Name: Relationship: Home: Address Line 1: Work: Address Line 2: Cell: City: State: Zip: Pager: /EXPERIENCE EDUCATION (Complete information below or attach resume.) Highest Degree/Grade Completed: Degree Earned: Dates Institution Honors (including honorary degrees) Dates Institution Previous Professional Experience Dates Institution Licensed Professional Practice and Professional Certification, if any: Date: Signature: *Required for Equal Opportunity purposes only
Duke University/Health System Instructions: The following information is required to process your employment at Duke. Please complete the form by entering a response in each field. If using a computer, tab to the next entry. A resume may be attached to this form in lieu of completing the section on “Education/Experience.” Campus address information may be completed by the department. After completing this form, print and sign. If you have a disability and would like to explore reasonable accommodations, please contact the Office for Disability Management Systems at 919-668-6213. TTY 919-668-1329 PERSONAL DATA (Printed or Typed Only) Last Name: (Family Name) First Name: (Given Name) M.I.: Known as: (Preferred Name) Date: Gender* Male Female Ethnicity* (select one) Hispanic/Latino Non-Hispanic/Latino Race* (select all that apply) American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Protected Veteran Self-Identification I identify as one or more of these classifications: Disabled Veteran Recently Separated Veteran Active Duty Wartime or Campaign Badge Veteran Forces Service Medal Veteran I am a protected veteran, but choose not to self-identify the classification I am NOT a protected veteran Voluntary Self-Identification of Disability Yes, I have a disability (or previously had a disability) No, I don’t have a disability I don’t wish to answer Citizenship US Citizen Lawful Permanent Resident Non-Resident (INS) Registered Duke Student N/A Undergraduate Freshman Sophomore Junior Senior Graduate/Professional Grad/Prof Marital Status Single Married U.S. Home Address Campus Address (if known) Address line 1: Address line 1: (Bldg. & Room Number of Physical Work Location) Address line 2: Address line 2: (P.O. Box Number) City: City: State: Zip: State: Zip: Telephone: Telephone: Person to be notified in case of emergency: Telephone numbers (provide all that apply) Name: Relationship: Home: Address Line 1: Work: Address Line 2: Cell: City: State: Zip: Pager: EDUCATION /EXPERIENCE (Complete information below or attach resume.) Highest Degree/Grade Completed: Degree Earned: Dates Institution Honors (including honorary degrees) Dates Institution Previous Professional Experience Dates Institution Licensed Professional Practice and Professional Certification, if any: Signature: Date: *Required for Equal Opportunity purposes only
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