MINNEAPOLIS VA MEDICAL CENTER

HUMAN RESOURCES MANAGEMENT SERVICES

# Employee Information Worksheet

PLEASE PRINT---USE BLOCK LETTERS

COMPLETE ALL ENTRIES

<table style="width:100%;">
<colgroup>
<col style="width: 6%" />
<col style="width: 11%" />
<col style="width: 6%" />
<col style="width: 13%" />
<col style="width: 16%" />
<col style="width: 1%" />
<col style="width: 7%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 5%" />
<col style="width: 7%" />
<col style="width: 0%" />
<col style="width: 14%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="14">NAME</td>
</tr>
<tr class="even">
<td colspan="4">Last</td>
<td colspan="10"></td>
</tr>
<tr class="odd">
<td colspan="4">Suffix (Jr, III, etc.)</td>
<td colspan="10"></td>
</tr>
<tr class="even">
<td colspan="4"><h1 id="first">First</h1></td>
<td colspan="10"></td>
</tr>
<tr class="odd">
<td colspan="4">Middle</td>
<td colspan="10"></td>
</tr>
<tr class="even">
<td colspan="4">Social Security Number</td>
<td colspan="10"></td>
</tr>
<tr class="odd">
<td colspan="4"><p>Date of Birth</p>
<p><u>(yyyy-mm-dd)</u></p></td>
<td colspan="4"></td>
<td colspan="4"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="14">OTHER NAMES</td>
</tr>
<tr class="odd">
<td colspan="4">NONE</td>
<td colspan="10"></td>
</tr>
<tr class="even">
<td colspan="4">Maiden Name</td>
<td colspan="10"></td>
</tr>
<tr class="odd">
<td colspan="4" rowspan="3">Aliases</td>
<td colspan="10"></td>
</tr>
<tr class="even">
<td colspan="10"></td>
</tr>
<tr class="odd">
<td colspan="10"></td>
</tr>
<tr class="even">
<td>Sex</td>
<td>Race</td>
<td colspan="2">Color Eyes</td>
<td colspan="3">Color Hair</td>
<td colspan="6">Height (f-ii)</td>
<td>Weight</td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="4"><p>Place of Birth</p>
<p>(City, State or Country)</p></td>
<td colspan="10"></td>
</tr>
<tr class="odd">
<td colspan="14">Current Residence</td>
</tr>
<tr class="even">
<td colspan="4">Street</td>
<td colspan="10"></td>
</tr>
<tr class="odd">
<td colspan="4">City</td>
<td colspan="10"></td>
</tr>
<tr class="even">
<td colspan="4">State</td>
<td colspan="10"></td>
</tr>
<tr class="odd">
<td colspan="4">ZIP</td>
<td colspan="10"></td>
</tr>
<tr class="even">
<td colspan="4">CITIZENSHIP (Country)</td>
<td colspan="10"></td>
</tr>
<tr class="odd">
<td colspan="4">TITLE of MY POSITION with the VA</td>
<td colspan="10"></td>
</tr>
<tr class="even">
<td colspan="14">SCARS, MARKS and TATTOOS</td>
</tr>
<tr class="odd">
<td colspan="4">NONE</td>
<td colspan="10"></td>
</tr>
<tr class="even">
<td colspan="4" rowspan="2"><p>List each</p>
<p>(type and location on body)</p></td>
<td colspan="2"></td>
<td colspan="5"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="5"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="14">FOR HR USE <em>ONLY</em></td>
</tr>
<tr class="odd">
<td colspan="3">Date of Prints</td>
<td colspan="2">Service Line</td>
<td colspan="4">NOA</td>
<td colspan="5">EOD</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td colspan="14">OPM Case Number</td>
</tr>
<tr class="even">
<td colspan="14"></td>
</tr>
</tbody>
</table>

**Location** Mpls VA Med Center 1 Veterans Drive Mpls MN 55417
**4M-109** **Human Resources**

To get fingerprinted: **Fax form first to 612.467.2287 (1^st^ day of
duty)**

**then call for appointment:** Don 612.467.4304, Donna 612.467.1898,
Denise 612.467.4344