Facilities Department Student Information

Name: __________________________________________________________

Local Address: _________________________________________________

________________________________________________________________

Permanent Address: _____________________________________________

________________________________________________________________

Local Phone #: _________________________________________________

Permanent Phone #: _____________________________________________

Social Security #: _____________________________________________

College/Department: ____________________________________________

# of units enrolled in this quarter: _______

Are you currently working in another department?

Yes _____ dates: _______________________________________________

No: _____

Do you have workstudy? _______

Do you want SurePay (direct deposit)? _______

Do you already have SurePay? _______