University of California, Irvine

By Leonard Morales,2014-05-07 21:53
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University of California, Irvine

    University of California, Irvine




     Last First Middle

    Department Title

    Prior University Service: Yes UC Campus No Date of Birth

     U.S. Citizen Permanent Resident Country

     Visa Type Visa End Date

    Permanent Home Address Street City State/Country Zip


     Area Code Telephone

    Current Home Address Street City State/Country Zip


     Area Code Telephone

    Current Business Address Street City State/Country Zip


     Area Code Telephone

Name and Permanent Address of person to be contacted in Case of Emergency:

Name Area Code Telephone

Street City State/Country Zip

Relatives or domestic partner employed by the University:

Name Relationship Department

Name Relationship Department

I certify that the information I have provided on this form and any attached supporting documentation is true and complete and

    that I have read and understand the privacy notice and nondiscrimination statement. (See Privacy Notification.)

    Signature Date

    01/09 UCI-AP-9

     Privacy Notification

    The State of California Information Practices Act of 1977 (effective July 1, 1978) requires the University to provide the following information to individuals who are asked to supply information about themselves:

    The principal reason for requesting the information on this form is for purposes of academic personnel administration and University public relations. University policy and state and federal statutes authorize the maintenance of this information.

    For academic personnel administrative purposes, furnishing all information requested on this form is mandatory. Failure to provide such information will delay or may even prevent completion of the action for which this form is being filled out. Information furnished on this form may be transmitted to the federal and state governments when required by law.

    Individuals have the right to review their own records in accordance with University personnel policy and collective bargaining agreements. Information on applicable policies and agreements can be obtained from campus or Office of the President Staff and Academic Personnel Offices.

The officials responsible for maintaining the information contained on this form are the campus Academic Vice Chancellors.

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