Personal Information Form - Non-Employee Page 2
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3WASHINGTON UNIVERSITY IN ST. LOUIS
Non-Employee Personal Information
Work Location:
____________________
____________________
__________
_____________
Primary Department:
Building Name:
Room #:
Campus Box #:
Emergency Contacts:
_____________________________________
____________________
____
____
Primary Contact Name:
Relationship:
Same Address:
Yes
No
______
______
______
______
______
______
Primary Contact Phone(s):
Home: (
)
/
Work: (
)
/
Other: (
)
/
___________________________________
____________________
____
____
Secondary Contact Name:
Relationship:
Same Address:
Yes
No
______
______
______
______
______
______
Secondary Contact Phone(s):
Home: (
)
/
Work: (
)
/
Other: (
)
/
Last Degree
Date(s)
Educational Information:
Major
School Name
State
Graduated?
Acquired/Terminal
Acquired
Degree?
___
___
___
___
Bachelor’s
Yes
No
Yes
No
___
___
___
___
Master’s
Yes
No
Yes
No
___
___
___
___
M.D. or Equivalent
Yes
No
Yes
No
___
___
___
___
Ph.D. or Equivalent
Yes
No
Yes
No
___
___
___
___
Additional Degree
Yes
No
Yes
No
For Postdoctoral Research Scholars Only:
Start Date
End Date
School Name
State
Previous Postdoctoral Experience
_____________________________________
____/____/____
Signature:
Date:
By typing my name above, I am certifying that all information on this payroll
intake form is true. I understand that Washington University may verify any
and all information I have provided. Falsification or omission of information
and credentials may result in the cancellation of employee or non-employee status.
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