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.

Form validation key:*

Enter the form validation key you were sent exactly as it appears.
Note: This key is case sensitive.

Personal Information id1946324208

Last name:*

First name:*

Middle name or initial:

Suffix:

Former name(s):

List all other names you have been known by.

Social Security Number:*

Enter Social Security Number, no dashes or spaces, numbers only.

Date of birth:*

Today

Gender:*

Marital status:

Contact Information id1847399704

Preferred phone number:*

( ) -

Type of phone number:

Cell / Mobile
Home phone
Work
Other (message service, etc.)

Alternate way to contact you:

( ) -

e.g., Cell / Mobile, FAX, Pager, Message Phone, etc.

Type of phone number:

Cell / Mobile
Home phone
Work
Other (message service, etc.)

Email address:*

Residence address:*

Include house number and street

Apartment, unit, or suite number:

City:*

State:*

ZIP code:*

County:

Do you have a separate mailing address?

YesNo

Education Information id1788947694

School(s) Attended id520699697

School name:

List the schools you attended chronologically, starting with your most recent.

School location:

Month and year attended from:

(E.g., MM/YYYY)

Month and year attended to:

Major:

Did you graduate?

YesNo

Do you need to add another school?

YesNo

Professional Licenses id2029994351

Do you have any professional licenses, certificates, or registrations that are applicable or required for your position?

YesNo

Prior State Service id-2049282660

Have you previously worked for a Washington state agency or state institute of higher education?

YesNo

Demographic Information id1957628473

What race or culture do you consider yourself? (Select all that apply)

Are you a person with a disability?

YesNo

Please refer to the end of this form for definitions.

What is your disability date?

(E.g., DD/MM/YYYY or MM/YYYY)

Veterans Information id-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.

Yes
No

What was your discharge date?

(E.g., DD/MM/YYYY or MM/YYYY)

Are you a Vietnam Era Veteran?

YesNo

Are you a Special Disabled Veteran?

Yes
No

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?

Non-Veteran or Unspecified Veteran Status
Discharged with a duty-related disability and less than one year of service
Honorably Discharged with one year or more of service receiving less than $500 per month
Retired Veteran receiving more than $500 per month
Separated or Retired Veteran receiving less than $500 per month
Surviving spouse of surviving registered domestic partner of a veteran

Definitions id1756450500

Please check the box at the end of this section to verify you have read and understand these definitions.*

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 Certification id-271232978

To certify the information submitted on this form, please read and agree to the following statement.*

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.

Type your full legal name:*

Date signed:*

Today