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Employee Information Form

Employee Information Form

The following information is necessary to complete your appointment in the personnel payroll system. Complete all sections that apply to you.

Sections that are labeled with an asterisk "*" are required.
Enter the form validation key you were sent exactly as it appears.
Note: This key is case sensitive.
Personal Informationid1946324208
List all other names you have been known by.
Enter Social Security Number, no dashes or spaces, numbers only.
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Contact Informationid1847399704
( ) -
Type of phone number:
( ) -
e.g., Cell / Mobile, FAX, Pager, Message Phone, etc.
Type of phone number:
Include house number and street
Do you have a separate mailing address?


Education Informationid1788947694
Indicate highest level of education completed:*


School(s) Attendedid520699697
List the schools you attended chronologically, starting with your most recent.
(E.g., MM/YYYY)
Did you graduate?
Do you need to add another school?
Professional Licensesid2029994351
Do you have any professional licenses, certificates, or registrations that are applicable or required for your position?


Prior State Serviceid-2049282660
Have you previously worked for a Washington state agency or state institute of higher education?


Demographic Informationid1957628473
What race or culture do you consider yourself? (Select all that apply)
Are you a person with a disability?
Please refer to the end of this form for definitions.
(E.g., DD/MM/YYYY or MM/YYYY)


Veterans Informationid-1008351000
Are you a U.S. Veteran?

Veterans Information – Employment preference and/or layoff preference is given to veterans who meet state qualifications, their spouses or registered domestic partner. Note: To qualify and receive veteran’s preference, you must also provide a copy of your record of discharge, DD214 or NGB Form 22 or alternate verification of military service.
(E.g., DD/MM/YYYY or MM/YYYY)
Are you a Vietnam Era Veteran?
Are you a Special Disabled Veteran?
If you checked yes, you may also meet the definition of a person with a disability (above). Please refer to the end of this form for definitions.
What is your military status?
What branch of the military did you serve in? (Select all that apply)


Definitionsid1756450500

Disability

Person with a Disability: For affirmative action data reporting purposes, people with disabilities are individuals with a permanent, physical, mental or sensory impairment that substantially limits one or more major life activities.

The impairment must be both permanent and material rather than slight, but not necessarily require a workplace accommodation. An impairment that is episodic or in remission is still a disability if it would substantially limit a major life activity when active. The determination of whether an impairment substantially limits a major life activity shall be made without considering temporary improvements made through mitigating measures such as medication, therapy, reasonable accommodation, prosthetics, technology, equipment, or adaptive devices (but not to include ordinary eyeglasses or contact lenses).

Disability Date: The date an individual was determined to have a disability.

Race and Culture

American Indian or Alaska Native: A person having origins in any of the original peoples of North and South America (including Central America), and who maintains a tribal affiliation or community attachment.

Asian: A person having origins in any of the original people of the Far East, Southeast Asia or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.

Black or African American: A person having origins in any of the Black racial groups of Africa.

Hispanic or Latino: A person having origins in any of the original peoples of Mexico, Puerto Rico, Cuba, Central or South America or other Spanish culture or origin, regardless of race. (Hispanic/Latino does not include persons from Portuguese speaking cultures such as Portugal or Brazil.)

Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa or other Pacific Islands.

White/Caucasian: A person having origins in any of the original peoples of Europe, the Middle East or North Africa.

Veterans

U.S. Veteran: Any person who:

  • has one or more years of active military service in any branch of the armed forces of the United States or
  • has less than one year of service and is discharged with a disability incurred in the line of duty or
  • is discharged at the convenience of the government and who, upon termination of such service, has received an honorable discharge, a discharge for physical reasons with an honorable record or a release from active military service with evidence of service other than that for which an undesirable, bad conduct or dishonorable discharge shall be given.

Discharge Date: The most recent discharge date from active military service in any branch of the armed forces of the United States, as indicated on the employee’s Certificate of Release or Discharge from Active Duty form DD214 or similar discharge paperwork.

Vietnam Era Veteran: A veteran of the U.S. military, ground, naval or air service, any part of whose service was during the period August 5, 1964 through May 7, 1975, who served on active duty for a period of more than 180 days and was discharged or released with other than a dishonorable discharge, or was discharged or released from active duty because of a service-connected disability. Includes any veteran of the U.S. military, ground, naval or air service who served in the Republic of Vietnam between February 28, 1961 and May 7, 1975.

Special Disabled Veteran: A person who is entitled to compensation under laws administered by the Department of Veteran Affairs for:

  • a disability rated at 30 percent or more; or,
  • a disability rated at 10 or 20 percent, if it has been determined that the individual has a serious employment disability; or
  • a discharge or release from active duty because of a service-connected disability.

I have read all of the above definitions.



Form Certificationid-271232978

I certify that all of the above information is true and complete.

By checking this box, you are stating that all statements and answers you provided are true and complete to the best of your knowledge. In addition, you understand that the state may verify information and that untruthful or misleading answers are cause for termination of employment.
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