Employee Name

Employee ID Number

Employee email address

Dependents
First Name Last Name

Address

City State Zip

Date of Birth Social Security

Dependents
First Name Last Name

Address

City State Zip

Date of Birth Social Security

Dependent
First Name Last Name

Address

City State Zip

Date of Birth Social Security

Dependent ID's will be made at the Student Life Office on:

Tuesday's from 8:00 am - 1:00 pm

Thursday's from 3:00 pm - 5:00 pm

Definition of Dependent as it relates to the Centre Dependent ID card is defined as an employee's spouse or domestic partner of the same or opposite gender, and any child (ren) of the spouse or domestic partner. “Children” includes biological children, stepchildren, children legally placed for adoption and legally adopted children. To be classified as a Dependent child, a child must be less than 25 years old.