Employment Specialist IRF

General Information

First name:		Last name:
Middle name:		Title:
*Employee ID:		*Department:	- Choose One - 01 - Biology 02 - MC&G 03 - G&G 04 - AOP&E 05 - PO 06 - MPC 09 - Rinehart CRC 14 - OAO 20 - Alvin 21 - Ship Ops 22 - R/V Atlantis 27 - R/V Knorr 30 - Facilities 50 - Directorate 51 - Education 52 - Controller's 53 - Procurement 54 - HR 55 - Development 56 - CIS 57 - Media Relations 59 - Communications 60 - MIS 61 - Services 62 - Board Relations 63 - EHS 64 - Library 65 - Conference Svs 66 - Graphic Svs 68 - Grant & Contracts 70 - JPS 76 - GFD
SS #:		Birth date:
Citizen:	Yes No	Gender:	Male Female
If not, which country:		VISA:
EEO Designation:	- Choose One - Hispanic or Latino Female Hispanic or Latino Male White Female White Male Black or African-Amer Female(Not Hispanic or Latino) Black or African-Amer Male(Not Hispanic or Latino) Native Hawaiian or Other Pac Isl Female(Not Hispanic or Latino) Native Hawaiian or Other Pac Isl Male(Not Hispanic or Latino) Asian Female (Not Hispanic or Latino) Asian Male(Not Hispanic or Latino) American Indian or Alska Native Female(Not Hispanic or Latino) American Indian or Alska Native Male(Not Hispanic or Latino) Two or More Races Female Two or More Races Male
Veteran:	N/A Vietnam Veteran Vietnam Disabled Vet Veteran Disabled Veteran Badges/Medals	Disabled:	N/A Hearing Impaired Sight Impaired Speech Disability Ambulatory Disability Mental Disabililty

Action

*Action:	N/A New assignment Adjustment Change in step Promotion Reclassification Merit increase Comp study adj Rehire New hire Change Dept Termination LOA Appt extension Status change
Effective Date:		Expiration Date:
Termination Date:		Reason:	N/A Voluntary Resignation Retired Involuntary Resignation End Appointment/Assign Deceased Laid Off 0 Hrs Worked/Calendar Yr

Employment Information

Employment:	Regular Temporary	Status:	Graded Exempt
Bi-Tech Type:	- Choose One - Guest Casual Education Independent Contractor Regular FT Regular 3/4 Regular 1/2 Temporary FT Temporary 3/4 Temporary 1/2	Department Transfer to:	- Choose One - 01 - Biology 02 - MC&G 03 - G&G 04 - AOP&E 05 - PO 06 - MPC 09 - Rinehart CRC 14 - OAO 20 - Alvin 21 - Ship Ops 22 - R/V Atlantis 27 - R/V Knorr 30 - Facilities 50 - Directorate 51 - Education 52 - Controller's 53 - Procurement 54 - HR 55 - Development 56 - CIS 57 - Media Relations 59 - Communications 60 - MIS 61 - Services 62 - Board Relations 63 - EHS 64 - Library 65 - Conference Svs 66 - Graphic Svs 68 - Grant & Contracts 70 - JPS 76 - GFD
Accrual Date:		Annual Salary:
Supervisor:		WHOI Experience:
Related Experience:		Total Related Experience:

Taxes

Federal:	N/A Exempt Head of Household Married Single Married File Single	# Allowances:
State:	N/A Exempt Head of Household Married Single Married File Single	# Allowances:

Office Information

Office Address:		MS#:
Ext.:

Education

Degree:	Major:	Institution:	Date:
N/A PhD Masters Bachelors Associates Diploma
N/A PhD Masters Bachelors Associates Diploma
N/A PhD Masters Bachelors Associates Diploma
N/A PhD Masters Bachelors Associates Diploma

Home Information

Primary Address:		Public:	Yes No
Home Phone:		Other Phone:

In Case of Emergency Notify

Name:		Relationship:
Address:		Phone:

ES Checklist

EEO Sheet: Salary Sheet: Submitted by:   Ann Sweck    Julie Fawkes    Beth Andrews    Susan Darmofalski   

Additional Comments

Comments: