Medical Residents Bio-Demographic Form | Human Resource Management and Development

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

Last Name *

First Name *

Middle Name *

Social Security Number *

Date of Birth *

Phone Number *

Email *

Position Title

Date of Hire

Gender *

F

M

Have you ever applied to GW as a student? *

Yes

No

Have you been affiliated with GW before? *

Yes

No

(e.g. as a student, faculty or staff member, affiliate)

GWID (If known)

Are you currently a GW student? *

Yes

No

Other name you may have had while previously affiliated with GW

Demographic Data

Employment Eligibility Status *

US Citizen

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 that you answer the following two questions on ethnicity and race.

1. Do you consider yourself to be Hispanic or Latino? (Persons of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race)

Yes

No

2. In addition, you may select one or more of the following racial categories to describe yourself:

Veterans' Status

Non-Veteran

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:

Month

Day

Year

*If other disability status, please list

If you need a reasonable accommodation, contact the EEO Department to make your request.

Are any relatives or members of your household currently employed with GW?

Yes

No

If yes, please list:

Name

Department

Relationship to you

Name 2

Department 2

Relationship to you 2

Address and Emergency Contact Information

Campus Address
(Address of primary office, if known)

Name of your department

Campus Street Address

Campus Address City

Campus Address Zip Code

Campus Phone Number

Home Address

Home Street Address *

Home City *

Home Zip Code *

Home Phone

Home Email Address

Emergency Contact Information

Emergency Contact Name *

Relationship to You *

Contact Street Address

Contact City

Contact Zip Code

Contact Phone Number *

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

Certification

Certification - Sign Here *