Employee Information Form
Human Resources
650-3774 MS-9054

HUMAN RESOURCES USE ONLY
ID#

INSTRUCTIONS: The following information is required of ALL Western Washington University employees. Required attached documents must include I-9 and W4. I understand that any of the information on this form may require verification.
 

Faculty  Professional Staff Classified Grad Assistant

 

Employee Name (as shown on SS Card):

Name Use Precedence:
1. Alternate Professional Name, if exists
2. Preferred First Name and Legal Last Name, if Preferred First Name exists and Alternate
  Professional Name does not exist
3. Legal Name if neither the Alternate Professional Name or Preferred First Name does not exist
Legal Name (as shown on SS Card)
Last:

 First:

Middle:

 
Preferred First Name:

Prefix:

Suffix:

 
Alternate Professional Name
Last:

 First:

Middle:

 
SS#:

Date of Birth:

 

US Citizen (check one): Yes   No 

Prior State Service: (Name of Institution/Agency):

From/To:

HOME ADDRESS (W-2 Address)

Street:

PO Box:

City:

State:      

Zip
County:
Telephone No. (Area Code)

OFFICE ADDRESS & DEGREE INFORMATION

Dept. Name:

Bldg/Room/Mail Stop:

Office TelNo:

Degree Information: 
(Optional)

 

Highest Degree:
Date Received:
Discipline:

DEPARTMENT OF RETIREMENT SYSTEMS PLAN VERIFICATION FOR EMPLOYER’S RECORD

Have you ever been a member of a WA State Retirement System?
NO (Retirement eligibility will be determined based on your position and workload at WWU.)
YES (if yes, please specify plan):  
  Teachers' Retirement System (TRS)
Public Employees' Retirement System (PERS)
Law Enforce Officers' & Fire Fighters' Ret System (LEOFF)
Washington State Patrol Retirement System (WSPRS)
Washington Judicial Retirement System (JRS)
Have you withdrawn your retirement contributions? No Yes N/A Don't know
Have you ever retired from one of the above WA State Retirement Plans? No Yes, Year
Did you retire from state service under the Early Retirement Act of 1992 or 1993? No Yes, Year
Have you participated in a State of Washington Higher Education Retirement Plan? No

Yes, Year

The submitter may optionally enter their email address below. Press SUBMIT to send it.
Your Email Address: