Volunteer Demographic Data Form (West Campus & HSC) Instructions: New Volunteers: Fill in all sections, sign and date Part 8; return to your department for processing Current Volunteers: Complete Part 1, update items as needed, then sign and date Part 8; return to your department for processing PART NEW VOLUNTEER Volunteer ID Number: CHANGE/UPDATE DATA NAME: Last Name, First Name, MI (as they appear on your Social Security Card For Name Changes use form HRSF0046 (Request to Change Primary/Legal Name) Prefix Mr Mrs Ms PART Suffix Dr Miss _ II III Jr Social Security Number (Campus ID #) Sr _ Volunteer Contact Information Residential Address Mailing Address: If Different From Residential Address Street Street/P.O Box City City County State Zip Code County State Zip Code Country Country Home Phone: ( ) Primary Cell Phone: - ( ) Secondary Primary Other/Alternate: - ( ) E-mail Address: - Secondary PART Affirmative Action Information Gender Marital Status Employee’s Birth Date Female Single Divorced Legally Separated Male Married Widowed Common Law Ethnic Origin: Please select one or more racial categories Birth Country Month Day Year Citizenship Status Asian Hispanic or Latino US Citizen Birth (Native) Permanent Resident Black American Indian or Alaska Native US Citizen Naturalized Non Resident Alien - Visa Type: _ Exp Date: _ White Native Hawaiian or other Pacific Islander Military Status Disability (Optional) No Military Service Vietnam Veteran Recently Separated Veteran Voluntary Firefighter? YES None Armed Forces Service Medal Veteran Other Protected Veteran Mobility Multiple Impairments Are you a disabled veteran? YES NO Learning Other: Are you a New York State Resident? YES NO Blind PART Language Skills (Optional) PART Emergency Contact Retired NYS Public Employee NO Are you a retiree of a local, state or other governmental agency? YES NO (If needed, more than one contact may be listed) Contact Name (Last, First) Contact Phone Number Relationship to Employee (Optional) ( ) - ( ) - PART Prior New York State/Research Foundation Employment Are you now or have you ever been employed by a New York State Agency or a State University of New York university or college? YES NO Are you currently employed by the Research Foundation? YES NO If yes to either of above, Name of Agency/Campus: Have you ever applied OR Attended Stony Brook University as a Student ? PART Diploma/Degree Year Earned YES NO Education Major Start Date: _/ _/ End Date: _/ _/ School, University or College PART School Address (City, State, Country) Acknowledgement I certify the information, which I have provided, is complete and accurate to the best of my knowledge Volunteer’s Signature Date Stony Brook University Use Only New Volunteers DO NOT complete this section The department will complete for you Department Reporting to Office Phone Office Phone Office Fax Page Number Building Zip + HSC/UH Floor Room Number HRSF0055 (12/10) Stony Brook University is an Affirmative Action/Equal Opportunity employer www.stonybrook.edu/hr