Bio-Demographic Form

Information below must match legal documentation (i.e. I-9 or Social Security Card).

Middle Name (Enter N/A if not applicable)

Email (where University ID will be sent)

Other name you may have had while previously affiliated with GW (i.e. Maiden Name)

Non-Citizen National of the US

Lawful Permanent Resident

Alien with temporary authorization

Colleges and universities are asked by many, including the federal government, accrediting associations, college guides, and our own college/university communities, to describe the ethnic/racial backgrounds of their students and employees. In order to respond to these requests, we ask you to answer questions 1 and 2 as applicable:

Black or African American

Native Hawaiian or Other Pacific Islander

American Indian or Alaska Native

Other Protected Veteran

Vietnam Veteran Only

Both Vietnam/Other Elig. Vet

Armed Forces Service Medal Veteran

If both Vietnam/other eligible veteran, Date of Separation:

*If other disability status, please list (Need a reasonable accommodation? Contact the EEO Department to make your request.)

Relationship to you 2

Campus (Primary Office Address, if known):

Name of Your Department

Emergency Contact Information:

Emergency Contact Name

Emergency Contact Relationship to You

Emergency Contact Address

Emergency Contact City

Emergency Contact State

Emergency Contact Zip

Emergency Contact Phone Number

Please report any changes to the information listed above to Human Resource Management and Development.

Certification - Sign Below

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DEMOGRAPHIC DATA

CAMPUS ADDRESS / EMERGENCY CONTACT INFORMATION

CERTIFICATION