Our Lady of the Lake University Employee Data Sheet NAE - Name and Demographic Information Full Name Test ame Fiat Name ‘ile Nae suffix: Oph. Qeap. Opa Cpr JomaQ] thp.()p-ts cra (cpr [otter Ge Bae Zp Coie County Country (non-resident), Home: Trea Cade) Phone KRDO “Bronson applicable O00 Mobile: “area Code ORR) — Phone OEE riesion applicable OOOO OLLU: Trea Code(GE Phone ARCO “tenton Fappicale WOOO Pager: Trea Code) Phone OTN cable WOON Identity: “ocial Security Namer EOE 000" Gender MF Date of Bia AOI Ethnic(s): [HIS Hispanic/Latino [INH Non-Hispanic/Latino If selected NHS Non-Hispanic/Latino please select from the following otherwise move on to the next question Race(s): (IAN - American/Alaska Native [[]AS- Asian [[]BL - Black or African American (CUnP - Hawaiian/Pacific Islander E]W - White Preferred Name: Ticks or Prefrred Name on Chock Siibs BIO — Biographical Information Birth Name: Tat ame Fr Name Mie ae Birth Place: Marital Status: []S-Single []M~Maried []D—Divorced ]W— Widowed PS. Emergency Contact Name: Firion ‘ide Name ast Name Denomination: CAG - Agnostic JAN ~ Anglican (DAS - Assembly of God [Ba — Baptist BU Buddhist JCA— Catholic |CC ~ Church of Christ CH Christian /DC~ Disciples of Christ EO — Eastem Orthodox JEP — Episcopalian HI—Hinda 1S—Islam JIE — Jewish JW Jehovah Witnesses LD ~ Latter Day Saints LU- Lutheran ME ~ Methodist NA ~ Nazarene ND —Non-denominational NO-None JOT Other PE Pentecostal JPR Presbyterian PT Protestant QU~ Quaker [isp - Seven Day Adventist Cluc— united Church of Christ CJUT— Unitarian Drivers License Number: State Issuing Drivers License: Personal/Professional Website:Our Lady of the Lake University Employee Data Sheet Native Language FR ~ French IT Kalan GR -German JEN English SP — Spanish JOT Other Primary Language: CJFR—French (Orr tatian Car German CEN - English sp - Spanish (or-other ‘Number of year offering instruction in Primary Language: Country where year of instruction in Primary Language occured: Resident State Resident County MINE ~ Military Information Registered for Selective Service: []¥es []No Veteran Type:[]V- Vietnam Vet []D-Dependent —-[]E~VA Educational Veteran Program Start Date: Benefits__ a End Date: Miltary Status:(C] A~ Active TIAR—Active Reserve LIR- Reserve Branch: JAP-AirForee QJARMY-Amy [J CG—Coast Guard. M~Marines (ONG —National Guard EINAVY — Navy Govemment Benefits: [J SS~ Social Security [JUN— Unemployment CFS—Food Stamps EMA — Medical Assistance Start Date End Date FINF~ Foreign Person Information Alien Statu’Registation Number: [JA~ Alien [[JRA~Resident Alien []C-US. Citizen Country of Citizenship: Country of Residence: ‘Immigration Status: (RA —Resident Alien [] MW - Migrant Worker (Cor - Alien —Not on Fi Visa Country Date of Entry: Birth City: Birth Country: Visa Type: (103— Nonimmigrant Student []F2—F-1 Dependent []M1 — Nonimmigrant Vocational Student Dv2— Dependent (G11 “Exchange Visitor F]J1 -Dependent Visa Number: ‘Visa Issue Date: Visa Expiration Date: Visa Issuing Post: : ‘Visa Issuing Country: __ _ ‘Admission Number: Passport Number: ______ Passport Issuing Country _ Passport Expiration Date Port of Entry: Country Entry Date: _ INAA~ Interests and Achievements ‘Affiliations, Groups or Organizations Interests: _ ____ Achievements: Interests — Achievements: a