Employee & Volunteer Information Form Human Resources 650-3774 | MS 9054 #New Form

Instructions: The following information is required of ALL Western Washington University employees.I understand that any of the information on this Web Form may require verification.

A Western email address is not required to complete this form.

Employee or Volunteer Information
Faculty Professional Staff Classified Grad Assistant Volunteer AmeriCorp
Name Use Precedence for Outlook and Campus Directory:
Alternate Professional Name, if exists. Preferred First Name and Legal Last Name, if Preferred First Name exists and Alternate Professional Name does not exist. 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 Name: First: Suffix:
Alternate Professional Name: Last: First: Middle:
US Citizen? Yes No Social Security #: Date of Birth:

Prior State Service
New employee are required to notify HR of prior state service within 30 days of employment to potentially earn credit for prior leave accrued.
Do you have any prior state service that you would like to notify HR of? Yes No
Name of Employer: HR Contact Information Name: Phone: Email:     Name of Employer: HR Contact Information Name: Phone: Email:     If additional employers, please email hr.forms@wwu.edu

Home Address (W-2 Address)
Street: P.O. Box: City: State: --Select-- AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Provinces AB BC MB NB NF NT NS ON PI PQ SA YT Zip: County: Phone:

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Have you withdrawn your retirement contributions?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

Routing Instructions
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Signatures and Attachments

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