UMIACS Employee/Visitor Information Form

*: Required fields.

Personal Information Name: * * (Lastname) (Firstname) (MI) Email Address: * (Please make sure it is entered correctly) Home Address: Address * City * State * Zip Code * Country * Phone * Sex Male Female Race Birthdate * Citizenship * Permanent Res. # Visa (if applicable): Visa Type Visa Number Expiration Date Passport Number

Most Recent Previous Employment Dates (from/to) Institution/Organization Department Title

Education Institution (City/State/Country) Degree Discipline Date Earned Honorary Degree * Yes No Yes No Yes No Yes No