Created by: Aneesa Lesley Updated 07/14/2015

PERSON OF INTEREST (POI)

PERSONAL DATA FORM *This form should ONLY be used for Non-Tax Levy Employees who have a need for entry into CUNYFirst.

GEN

ERAL

INFO

RMAT

ION

_______ Prefix ___________________________________________ Last Name ___________________________________________ First Name Middle Name CO

NTA

CT IN

FORM

ATIO

N

___________________________________________ Address Apt # ___________________________________________ City State Zip ( )______________ ( )________________ Home Telephone # Work Telephone #

PERS

ON

AL IN

FORM

ATIO

N

___________________________________________ Social Security Number

Gender: Male Female __________________________________________ Date of Birth (MM/DD/YYYY)

ETHN

ICIT

Y

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

MAR

ITAL

STA

TUS

Married Single Divorced Legally Separated Widowed

VETE

RAN

STA

TUS

Veteran – other than Vietnam Veteran – Vietnam

EMER

GEN

CY C

ON

TACT

1

__________________________________________ Last Name ___________________________________________ Address Apt # ___________________________________________ City State Zip ( _ )_____________ ( _ )________________ Home Telephone # Cell Phone #

EMER

GEN

CY C

ON

TACT

2

___________________________________________ Last Name ____________________________________________ Address Apt # ____________________________________________ City State Zip ( _ )_____________ ( _ )________________ Home Telephone # Cell Phone #

EDU

CATI

ON

AL D

ATA

Highest Educational Level: High School Diploma or Equivalency Associate's Degree Bachelor's Degree Master's Degree Doctorate's Degree

JOB

INFO

RMAT

ION

____________________________________________ Department Start Date End Date____________________________________________ Title Supervisor ____________________________________________ Employee’s Signature Date

FOR HUMAN RESOURCES USE ONLY

POS # CUNYFIRST Entry By Date