Fillable Application for Employment Packet Part-Time Coaching or Stipend (Wenatchee Valley College)

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Application for Employment Packet Part-Time Coaching or Stipend (Wenatchee Valley College)

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WENATCHEE VALLEY COLLEGE
Application for Employment Packet
Part-Time Coaching or Stipend Position (Please print single sided)
This application packet should ONLY be filled out if an individual has been offered a part-time job as a coach or
other job paid as a stipend. This form is not for hourly, volunteer or part-time faculty.
The following checklist is provided to help the new employee and the college. All forms must be completed—
and required documentation provided—before the application is considered complete.
Application for Employment – Part-Time Coaching or Stipend Position
Federal and State Reporting Form
This information allows the college to complete statistical reports on the composition of applicant and
employee pools for federal and state agencies. Although this information is optional for applicants, it is
required for all employees of WVC.
SBCTC Verification of Retirement Plan Status Form
This information tells us if you are or ever have been a member of a Washington state retirement
system or if you are concurrently working for another employer who is covered by these systems. You
may be eligible for contributions into the system while you are an employee at Wenatchee Valley
College.
W-4 Form
Double click the pushpin on the page and the W-4 form will download. Fill it out and print. This form
needs to be completed so the college can withhold the correct federal income tax from your pay.
I-9 Form – Employment Eligibility Verification
Federal law requires that employers see certain identification documents that establish both the identity
and the eligibility of a potential employee to work in the United States. Although the documentation
requirement for the I-9 can be met with a variety of documents (most use a social security card and
driver’s license), it is the policy of human resources that a copy of the individual’s social security
card must be provided to the human resources office (or the card is viewed by an HR staff
member). This requirement allows the college to make sure the name and number on the card is
entered into our payroll system correctly.
Public Employees Benefit Board (PEBB) Benefit Eligibility Worksheet A-1 (must be signed)
The worksheet has been completed with the assumption the new employee is not going to meet the
benefit eligibility threshold. Contact human resources for questions regarding this worksheet. A copy of
the signed worksheet will be provided to the new employee after it is received in human resources.
Safety Information (must be signed)
This information must be provided to all employees for the college.
Electronic Fund Transfer (EFT) Form (must be signed)
This form is needed if you want your pay electronically deposited in your bank account. If not, your pay
will be downloaded to a debit card called FOCUS issued by U.S Bank.
Employer Notice of Medical Insurance Exchange (information only—no need to return)
Questions regarding any part of the application process can be directed to human resources at 509-682-6440.
Assistanc
e will be made available in the application and pre-employment screening processes for
applicants with disabilities who request such assistance in advance
1300 Fifth Street, Wenatchee WA 98801-1799 Wenatchee (509) 682-6440 – TDD (509) 682-6837
Omak (509) 422-7800 – TDD (509) 422-7802
Please type or print clearly
PERSONAL DATA
Last Name First MI Home Phone
Home Address
Work Phone
City
State ZIP Email Address Cell Phone
POSITION APPLIED FOR
Title Location (campus) Date
Have you ever worked for this college or any other Washington state agency? No Yes If yes, when _______________________________
EMPLOYMENT HISTORY (List most recent experience first–You may attach a résumé instead but it must list dates of employment)
Employer
City, State From (month/year) to (month/year)
Job Title Hours/Week Supervisor (name/title) Telephone
Specific Duties
Employer
City, State From (month/year) to (month/year)
Job Title Hours/Week Supervisor (name/title) Telephone
Specific Duties
Employer
City, State From (month/year) to (month/year)
Job Title Hours/Week Supervisor (name/title) Telephone
Specific Duties
Employer
City, State From (month/year) to (month/year)
Job Title Hours/Week Supervisor (name/title) Telephone
Specific Duties
Employer
City, State From (month/year) to (month/year)
Job Title Hours/Week Supervisor (name/title) Telephone
Specific Duties
May we contact all employers/supervisors listed? Yes No Indicate exceptions:
WENATCHEE VALLEY COLLEGE
Application for Employment
Part-Time Coaching or Stipend Position
EDUCATION Check the following diploma/degrees you have earned:
AA/AAS Bachelor's Master's DoctorateHigh School or GED
List colleges and business, trade, and other schools you have attended, beginning with the most recent. Attach additional pages if necessary.
Name and Location
Major
Degree
Dates Attended
Name and Location
Major
Degree
Dates Attended
Name and Location
Major
Degree
Dates Attended
OTHER TRAINING — SEMINARS, WORKSHOPS and LECTURES (Indicate length of training)
Please answer the following questions and sign below.
Are you a citizen or do you have a visa which permits you to work in the United States? Yes No
Do you have any relatives who work for WVC? Yes No If Yes, please list their name(s) ___________________
Within the past 10 years, have you been convicted of, or released from prison for any crimes excluding parking tickets or traffic
citations? Yes No
If yes, give all conviction dates, prison release dates and the nature of the offenses. Criminal history background checks will be
conducted where required by law. Please note that a conviction/criminal history record does not necessarily disqualify an
individual from employment at Wenatchee Valley College.
The information I have supplied is true to the best of my knowledge. I understand that false statements on this application may be
considered sufficient cause for elimination of my application from consideration, or, if employed, for dismissal. If employment is
obtained under this application, I will comply with all rules and regulations of Wenatchee Valley College.
I agree to be responsible for any college property and equipment issued to me until returned to the college and agree to pay for
any property and equipment which I do not return.
I authorize and release from liability my current and former employers and personal references to provide any information they
may have about me, unless I specifically request otherwise.
Signature
Date
Equal Opportunity Employer: Wenatchee Valley College is committed to a policy of equal opportunity in employment and
student enrollment. All programs are free from discrimination and harassment against any person because of race, creed, color,
national or ethnic origin, sex, sexual orientation, gender identity or expression, the presence of any sensory, mental, or physical
disability, or the use of a service animal by a person with a disability, age, parental status or families with children, marital status,
religion, genetic information, honorably discharged veteran or military status or any other prohibited basis per RCW 49.60.030,
040 and other federal and laws and regulations, or participation in the complaint process.
The following persons have been designated to handle inquiries regarding the non-discrimination policies and Title IX compliance
for both the Wenatchee and Omak campuses:
To report discrimination or harassment: Title IX Coordinator, Wenatchi Hall 2322M, (509) 682-6445, title9@wvc.edu.
To request disability accommodations: Student Access Director, Wenatchi Hall 2133, (509) 682-6854, TTY/TTD: Dial
711, sas@wvc.edu. Revised 1/20 tm
https://www.irs.gov/pub/irs-pdf/fw4.pdf[1/24/2020 10:59:20 AM]
W-4 Form 2020 (fill out and print)
The file https://www.irs.gov/pub/irs-pdf/fw4.pdf is an Adobe XML Form document that has been embedded in this
document. Double click the pushpin to view.
AA
Confidential Information for Federal and State Reporting
Name Position
Wenatchee Valley College is required by law to report the composition of its employment force to the government. The
information on this form will be filed separately from your main application form. Safeguards are used to prevent the
discriminatory abuse of this information. It will be available only to the person responsible for governmental reporting. We ask
your voluntary cooperation in responding to the questions below. Wenatchee Valley College is an equal opportunity employer.
1. Are you 40 years of age or older?
Yes
No
2. Military Status (Please check all that apply)
Non-Veteran
Disabled Veteran other
than Vietnam (DO)
Veteran other
than Vietnam (OV)
Disabled Vietnam-Era
Veteran (DV)
Vietnam-Era
Veteran (VV)
Spouse of Deceased
Veteran (SV)
Date of Discharge: __________
3. Disability Information
For affirmative action purposes, people with disabilities are
persons with a permanent physical, mental, or sensory
impairment which substantially limits one or more major life
activities. Physical, mental, or sensory impairment means:
(a) any physiological or neurological disorder or condition,
cosmetic disfigurement, or anatomical loss affecting one or
more of the body systems or functions; or (b) any mental or
psychological disorders such as mental retardation,
organic brain syndrome, emotional or mental illness, or any
specific learning disability. The impairment must be
material rather than slight, and permanent in that it is
seldom fully corrected by medical replacement, therapy, or
surgical means.
Do you have a physical, sensory, or mental condition
that substantially limits any of your major life
functions, such as working, caring for yourself,
walking, doing things with your hands, seeing,
hearing, or learning?
Yes No
DEFINITIONS
4. Gender
Male
Female
5. What is your race?
(Please check one or more unless you are
Hispanic or Latino—see definitions)
Caucasian/White (800)
Black or African American (870)
American Indian (597)
Please specify principal tribal
affiliation: ________
Alaskan Native
Aleut (941)
Eskimo (935)
Other Native American: _____
Asian
Chinese (605)
Japanese (611)
Cambodian (604)
Korean (612)
Vietnamese (619)
Filipino (608)
Other Asian: Please specify _____
Native Hawaiian or Other Pacific Islander
Native Hawaiian
Pacific Islander. Please specify __
6. Are you Hispanic or Latino?
No, (999)
Yes, Cuban (709)
Yes, Puerto Rican (727)
Yes, Mexican, Mexican-American, Chicano (722)
Yes, Other Hispanic or Latino (for example:
Argentinean, Colombian, Dominican, Nicaraguan,
Salvadoran, Spaniard, etc.).
Please specify: _______
Caucasian/White: A person having origins in any of the original peoples of Europe, the Middle East or North Africa.
Black or African American: A person having origins in any of the black racial groups of Africa.
Hispanic or Latino: A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.
Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian, subcontinent. This area includes, for
example, Cambodia, China, India, Japan, Korea, Malaysia, the Philippine Islands, Thailand and Vietnam.
American Indian or Alaskan Native: A person having origins in any of the original peoples of North and South America (including Central
America), and who maintains cultural identification through tribal affiliation or community attachment.
Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific
Islands.
How did you learn about this opportunity? Please check all that apply:
Newspaper or other media advertisement (specify) _____________
WorkSource Washington _____________
Internet Posting (specify Website) _____________
Other (specify) _____________
Revised 3/3/11 tm
SID
STATE BOARD RETIREMENT PLAN
Verification of Retirement Plan Status
To determine your retirement plan options, we require your completion of the appropriate sections listed below.
State law details certain conditions for mandatory retirement system membership. RCW 41.50.130 and State
Board policy requires employers to solicit this information.
Employee Name:
Social Security/Employee ID #:
Please check the appropriate box:
1. Have you ever been a member of a Washington State Retirement
System? (TRS, PERS, SBRP*, etc.)
Yes
No
2. Are you currently making contributions and earning service credit
through employment with another public employer, such as
another college, the Washington Student Achievement Council
(WSAC) or the State Board for Community and Technical
Colleges (SBCTC)?
If yes, list the name of the other college or agency:
Yes No
3. If your response to either one of the above questions is Yes, what system and plan? (check all that apply)
Teacher's Retirement System (TRS): Plan 1 Plan 2 Plan 3
Public Employees' Retirement System (PERS): Plan 1 Plan 2 Plan 3
Other Washington State Plan:
With the following employer:
4. Have you withdrawn your contributions?
Yes
No
5. Have you ever retired from one of the retirement systems listed
above?
6. Are you currently (or were you last quarter) a contributing
participant of SBRP at a community/technical college, the WSAC,
or the State Board listed above?
Yes No
Yes No
I hereby certify the statements completed above are true and complete. Please sign and date:
Employee's Signature
Date
* TRS Teachers' Retirement System
PERS Public Employees' Retirement System
SBRP State Board Retirement Plan
Retirement Plan Status, Verification of June 2013
USCIS
Form I-9
OMB No. 1615-0047
Expires 10/31/2022
Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services
Form I-9 10/21/2019
Page 1 of 3
►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically,
during completion of this form. Employers are liable for errors in the completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an
employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the
documentation presented has a future expiration date may also constitute illegal discrimination.
Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later
than the first day of employment, but not before accepting a job offer.)
Last Name (Family Name)
First Name (Given Name)
Middle Initial
Other Last Names Used (if any)
Address (Street Number and Name)
Apt. Number
City or Town
State
ZIP Code
Date of Birth (mm/dd/yyyy)
-
-
Employee's E-mail Address
Employee's Telephone Number
U.S. Social Security Number
1. A citizen of the United States
2. A noncitizen national of the United States (See instructions)
3. A lawful permanent resident
4. An alien authorized to work until
(See instructions)
(expiration date, if applicable, mm/dd/yyyy):
(Alien Registration Number/USCIS Number):
Some aliens may write "N/A" in the expiration date field.
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in
connection with the completion of this form.
I attest, under penalty of perjury, that I am (check one of the following boxes):
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9:
An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.
1. Alien Registration Number/USCIS Number:
2. Form I-94 Admission Number:
3. Foreign Passport Number:
Country of Issuance:
OR
OR
QR Code - Section 1
Do Not Write In This Space
Signature of Employee
Today's Date (mm/dd/yyyy)
Preparer and/or Translator Certification (check one):
I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.
(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)
I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my
knowledge the information is true and correct.
Signature of Preparer or Translator
Today's Date (mm/dd/yyyy)
Last Name (Family Name)
First Name (Given Name)
Address (Street Number and Name)
City or Town
State
ZIP Code
Employer Completes Next Page
Form I-9 10/21/2019
Page 2 of 3
USCIS
Form I-9
OMB No. 1615-0047
Expires 10/31/2022
Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services
Section 2. Employer or Authorized Representative Review and Verification
(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You
must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists
of Acceptable Documents.")
Last Name (Family Name) M.I.
First Name (Given Name)
Employee Info from Section 1
Citizenship/Immigration Status
List A
Identity and Employment Authorization
Identity
Employment Authorization
OR List B AND List C
Additional Information
QR Code - Sections 2 & 3
Do Not Write In This Space
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee,
(2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the
employee is authorized to work in the United States.
The employee's first day of employment (mm/dd/yyyy):
(See instructions for exemptions)
Today's Date (mm/dd/yyyy)
Signature of Employer or Authorized Representative
Title of Employer or Authorized Representative
Last Name of Employer or Authorized Representative
First Name of Employer or Authorized Representative
Employer's Business or Organization Name
Employer's Business or Organization Address (Street Number and Name)
City or Town
State
ZIP Code
Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)
A. New Name (if applicable)
Last Name (Family Name)
First Name (Given Name)
Middle Initial
B. Date of Rehire (if applicable)
Date (mm/dd/yyyy)
Document Title Document Number
Expiration Date (if any) (mm/dd/yyyy)
C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes
continuing employment authorization in the space provided below.
I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if
the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.
Signature of Employer or Authorized Representative
Today's Date (mm/dd/yyyy)
Name of Employer or Authorized Representative
Wenatchee Valley College
Wenatchee Valley College, 1300 Fifth St
Wenatchee
WA
98801
LISTS OF ACCEPTABLE DOCUMENTS
All documents must be UNEXPIRED
Employees may present one selection from List A
or a combination of one selection from List B and one selection from List C.
LIST A
2. Permanent Resident Card or Alien
Registration Receipt Card (Form I-551)
1. U.S. Passport or U.S. Passport Card
3. Foreign passport that contains a
temporary I-551 stamp or temporary
I-551 printed notation on a machine-
readable immigrant visa
4. Employment Authorization Document
that contains a photograph (Form
I-766)
5. For a nonimmigrant alien authorized
to work for a specific employer
because of his or her status:
Documents that Establish
Both Identity and
Employment Authorization
6. Passport from the Federated States
of Micronesia (FSM) or the Republic
of the Marshall Islands (RMI) with
Form I-94 or Form I-94A indicating
nonimmigrant admission under the
Compact of Free Association Between
the United States and the FSM or RMI
b. Form I-94 or Form I-94A that has
the following:
(1) The same name as the passport;
and
(2) An endorsement of the alien's
nonimmigrant status as long as
that period of endorsement has
not yet expired and the
proposed employment is not in
conflict with any restrictions or
limitations identified on the form.
a. Foreign passport; and
For persons under age 18 who are
unable to present a document
listed above:
1. Driver's license or ID card issued by a
State or outlying possession of the
United States provided it contains a
photograph or information such as
name, date of birth, gender, height, eye
color, and address
9. Driver's license issued by a Canadian
government authority
3. School ID card with a photograph
6. Military dependent's ID card
7. U.S. Coast Guard Merchant Mariner
Card
8. Native American tribal document
10. School record or report card
11. Clinic, doctor, or hospital record
12. Day-care or nursery school record
2. ID card issued by federal, state or local
government agencies or entities,
provided it contains a photograph or
information such as name, date of birth,
gender, height, eye color, and address
4. Voter's registration card
5. U.S. Military card or draft record
Documents that Establish
Identity
LIST B
OR AND
LIST C
7. Employment authorization
document issued by the
Department of Homeland Security
1. A Social Security Account Number
card, unless the card
includes one of
the following restrictions:
2. Certification of report of birth issued
by the Department of State (Forms
DS-1350, FS-545, FS-240)
3. Original or certified copy of birth
certificate issued by a State,
county, municipal authority, or
territory of the United States
bearing an official seal
4. Native American tribal document
6. Identification Card for Use of
Resident Citizen in the United
States (Form I-179)
Documents that Establish
Employment Authorization
5. U.S. Citizen ID Card (Form I-197)
(2) VALID FOR WORK ONLY WITH
INS AUTHORIZATION
(3) VALID FOR WORK ONLY WITH
DHS AUTHORIZATION
(1) NOT VALID FOR EMPLOYMENT
Page 3 of 3
Form I-9 10/21/2019
Examples of many of these documents appear in the Handbook for Employers (M-274).
Refer to the instructions for more information about acceptable receipts.
N
N
Decision
No
Date
Date


EMPLOYEE ELIGIBILITY NOTIFICATION
1. Stacking Hours Within an Agency (WAC 182-12-114 (1)(c))
Enter a
Y or N
0
Enter a
Y or N
They are working two or more positions or jobs in the agency (concurrent stacking); or have
moved from one position or job to another in the agency (consecutive stacking).
b. Anticipated to work for at least 8 hours in each month; and
3. Eligibility Decision
2. Requirements for Eligibility (WAC 182-12-114 (1)(a))
An employee is eligible if they are:
a. Anticipated to work an average of at least 80 hours per month;
Employee has informed their employer that:
c. For more than 6 consecutive months.
Excluded hours:
4. Date of Eligibility (WAC 182-12-114 (1)(b)(i))
PEBB Benefit Eligibility
A-1 (Worksheet C): Provided to the employee as notification
Newly hired employee (hourly/salaried)
Not needed at this time
Employee Email Address: (optional)
Employee Name:
0
Employee ID:
0
If the answer is "Yes" to all requirements, the employee is benefits-eligible.
Go to section #4 of this worksheet.
ŸŸŸPEBB website
Insurance is effective as of this date.
If an answer was "No" to any of the requirements, the employee is not benefits-eligible at this
time. Go to section #8 of this worksheet.
6. New Employee Resources to Enroll in PEBB Benefits
The following resources are available for newly eligible employees about PEBB benefits:
The employee is eligible from the date of employment. This is typically your first day of work.
5. Coverage Begins: (WAC 182-12-114 (1)(d))
The PEBB Employee Enrollment Guide (which includes enrollment forms)
www.hca.wa.gov/public-employee-benefits/employees/how-enroll
Revised: 12/2019 1
Due Date
Date
Date
The PEBB Employee Enrollment/Change form must be received by the employing agency no later
than 31 days after the employee becomes eligible for PEBB benefits.
• I (the employee) have reviewed the above information and acknowledge the decision made. I understand I can access PEBB
rules and guidance on the above decision through the PEBB website (www.hca.wa.gov/employee-retiree-benefits/rules- and-
policies/pebb-rules-and-policies), specifically WAC 182-12-114 and 182-12-131.
• I understand if I have a change that affects my eligibility for PEBB benefits, my employer will notify me. I also understand I have
the right to ask my employer to re-evaluate my eligibility at any time.
• I understand it is my responsibility to inform my employer immediately if I am returning from layoff status within 24 months of my
original eligible position ending (date of layoff). (For the limited purpose of determining PEBB benefit eligibility, "layoff" is defined
in WAC 182-12-109 and there are examples in WAC 182-12-129 and 182-12-133 (1)(b)(v)).
https://www.hca.wa.gov/about-hca/file-appeal-pebb
www.metlife.com/wshca
If enrolling in the Medical FSA and/or DCAP*, the PEBB Medical FSA and DCAP Enrollment form must
be received by the employing agency no later than 31 days after the employee becomes eligible for
PEBB benefits.
*Available to state and higher education institution employees only.
Auto or home insurance may be applied for at any time with Liberty Mutual.
https://www.hca.wa.gov/public-employee-benefits/employees/dependent-verification
The PEBB MetLife Enrollment/Change form must be received by MetLife or enrollment through the
MetLife MyBenefits portal no later than 31 days after the employee becomes eligible for PEBB
benefits. If supplemental life insurance is requested after 31 days, or the amounts requested are over
the guaranteed issue amounts, evidence of insurability (statement of health) will be required. Note:
Supplemental accidental death and dismemberment (AD&D) insurance will not require evidence of
insurability (statement of health).
7. Form Submission Dates: (WAC 182-08-197 (1)(a))
Place a signed copy in the employee's file and provide a copy to the employee.
The PEBB Long-Term Disability (LTD) Enrollment/Change form* must be received by the employing
agency no later than 31 days after the employee becomes eligible for PEBB benefits. If supplemental
LTD insurance is requested after 31 days, evidence of insurability (statement of health) will be
required.
*Port Commissioners and seasonal employees who work a season of less than 9 months are eligible for
basic LTD only.
Employee Signature
8. Signature and Date: To be reviewed and signed by the employee and employer
Failure to submit your forms timely will result in a default enrollment as follows: Uniform Medical Plan Classic with a
monthly premium of $104, Uniform Dental Plan, basic life, basic AD&D insurance, basic LTD, dependents will not be
enrolled, and a $25 per acount monthly tobacco use premium surcharge will be incurred (WAC 182-08-197 (1)(b)).
Forms must be submitted even if the employee chooses to waive medical coverage.
• I understand it is my responsibility to immediately inform my employer if I have or obtain multiple jobs or positions within the
agency.
• I acknowledge I have the right to appeal this and any future eligibility decisions for PEBB benefits made by a PEBB-participating
employing agency through the PEBB appeals process (Chapter 182-16 WAC).
• I understand the PEBB appeals process begins with requesting a review from my employer. (For a complete explanation of the
appeals process and appeal forms, visit the PEBB website)
https://www.hca.wa.gov/employee-retiree-benefits/public-employees/auto-and-home-insurance
Agency/Sub Agency
WVC/686
Agency Representative Signature
If enrolling dependents, valid Dependent Verification (DV) documents must be received by the
employing agency no later than 31 days after the employee becomes eligible for PEBB benefits. A
list of valid DV documents is available on the PEBB website:
2
WVC EMERGENCY INFORMATION
Administration/WVC Incident Management Team: 682-6514
Security Patrol: 682-6911 Safety Officer 682.6659 or 679.2274
Facilities and Operations: 682-6450 Weekends and/or After 4:00 pm 860-2250
EVACUATION
1. Fire Alarm and/or your building point of contact verbally announces an evacuation.
2. Incident Management Team establishes an exterior Incident Command Post.
3. All employees with radios report to the Incident Command Post.
4. Employees without students report to the Evacuation Team Leader for possible assignment.
5. Instructors and Department Heads will organize students/employees for building departure:
Close all doors as you leave the building.
Leave the building via the closest -safe exit.
Gather your class/employees at your buildings “Evacuation Assembly Area”.
Conduct a roll call then forward information to your Evacuation Team Leader via runner.
Wait for a WVC Team authorization, before re-entering the building.
Check your classroom/work area and report anything unusual to administration.
Debrief your students/employees.
FIRE
1. If you discover smoke or fire, pull a fire alarm as you leave the building. Insure that 911 have been
contacted with incident information.
2. Use the above evacuation procedure for any fire or suspected fire.
3. Leave room lights on and close all doors as you exit. Do not lock!
4. Employees choosing to use a Fire Extinguisher; use caution and apply your training.
LOCKDOWN
1. If an interior threat is discovered a Lockdown Alert will be made via an Emergency Text Alert.
2. Employees at exposed work stations, move to your predetermined safe room.
3. Employees occupying an office, classroom or storage area; lock or barricade yourself in and remain in
place.
4. If inside, close, lock and cover all interior windows and glass panels.
5. Leave curtains/blinds open on exterior windows.
6. Move everyone away from interior doors and windows.
7. Turn off lights and keep quiet. Set your cell to vibrate only. Don’t open your door for any reason.
8. Anyone in transit between rooms shall immediately seek shelter in the closest room.
9. Anyone in transit between buildings shall immediately leave campus.
10. Lockdown is concluded when police or a WVC Team member enters your location.
11. Follow their instructions.
INJURY ACCIDENT
1. Call 911 if requested by injured party (victim) or if in your judgment, such assistance is obviously
required.
2. Calling 911 with any campus phone also notifies the WVC Incident Management Team.
3. If a cell phone was used to call 911, now call Administration to alert the WVC Team.
4. Provide appropriate First Aid to the victim(s).
5. If alone with the victim, take actions that will assist the ambulance in finding your location.
SHELTER IN PLACE
1. You may be notified of this situation by phone, ETA or building point of contact.
2. If inside, stay inside.
3. If outside immediately enter any building.
4. Facility Department will:
Activate automatic door locking where available.
Stop all air exchanges in all buildings.
Instructors will close and lock all exterior classroom door(s) or window(s).
All employees will work with the Incident Management Team to secure all exterior doors.
Do not open exterior doors, for any reason, until the all-clear is given.
EARTHQUAKE
DROP To the floor.
COVER Take cover under a sturdy piece of furniture. Against a load bearing wall is best. Protect
your head and neck with your arms. Avoid danger spots near windows, hanging objects,
mirrors or tall furniture.
HOLD On to sturdy objects and be prepared to move with it. Hold until the ground stops shaking
and it's safe to move.
EVACUATE When the shaking stops, leave the building via the closest - safe exit and follow evacuation
procedures as described above.
BOMB THREAT
1. May be delivered in many formats.
2. Notify Administration to alert the WVC Team and they will call 911.
3. Turn off cell phones and/or walkie-talkies (radio waves could trigger a bomb).
4. Our Incident Management Team will coordinate with emergency responders.
5. Follow standard evacuation procedures if the alarm is sounded.
6. If you see something suspicious REPORT IT—DON'T TOUCH IT!
The items above are generally focused toward WVC campuses. Employees that work at sites other than
WVC campuses are encouraged to learn the emergency information from the site where you are based.
Additionally, to learn about the WVC safety committee, please go to WVC Commons, Sites A-Z, Safety,
Shared Documents, Safety Committee.
If you are involved in an accident please contact administrative services at 682.6514.
____________________________________________ ____________________________
Employee Signature (I have received this information) Date
Rev 5/15/13 tm
EMPLOYEE: (1)
(2)
(3)
(4)
Must know your WVC Employee ID number and PIN number to login to the ETL system to get
the summary of your deductions-and we can provide that to you.
Complete the upper portion of the form, sign and date.
If possible, have the designated financial institution complete the lower portion of the form. If you fill it
out yourself, PLEASE double check the numbers.
Keep with your application packet or return the completed form to:
Payroll Name (Last, First, Initial)
Social Security Number
Agency
WVC
Agency Code
686
Employee Address
In accordance with RCW 43.08.085, I hereby authorize and request the State, until this authorization is revoked as described
below, to transfer the full amount of my state salary, after mandatory and authorized deductions, to the designated financial
institution for deposit in my:
Checking Account Savings Account
In the event that the State may be legally obligated to withhold any additional part of my salary payment for any reason, I
understand that the State shall have the authority to immediately terminate any transfer made under this authorization.
In the event that the exercise of this authorization for any reason results in an overpayment of salary or wages actually due and
payable to me, I hereby authorize the State to either:
A) Withhold a sum equal to the overpayment from my next state salary payment; or
B) Debit my above-identified checking or savings account for an amount not to exceed said overpayment.
If any action taken by me, without adequate notification to WVC payroll office, results in non-acceptance of the transfer by the
designated financial institution, I understand that the State assumes no responsibility for processing supplemental payroll
payments until the funds are returned to the agency by the financial institution.
This authority is in force until written notification is received from me regarding its’ termination, or my death. This authorization will
not be in effect for any payments made on or after separation from state service.
Employee Signature _______________________________ Date __________________
FINANCIAL INSTITUTION TO COMPLETE ITEMS BELOW (if possible)
Name of Financial Institution
Authorized Signature of Financial Institution Officer
Address
Title/Date
NUMBER OF DEPOSITOR ACCOUNT TO BE CREDITED
-
Routing Number Account Number
STATE OF WASHINGTON
ELECTRONIC FUNDS TRANSFER
OF SALARY AUTHORIZATION
Note: once this form is received, you will be mailed one more paper check.
WVC Payroll Office
1300 Fifth St
Wenatchee WA 98801
— HUMAN RESOURCES —
The Affordable Care Act (ACA) Notice of Health Insurance Marketplace Coverage Options and Your Public
Employees Benefits Board (PEBB) Benefits General Information
Beginning in 2014, most individuals will be required to have health insurance coverage. There will be a new way to buy
health insurance through the new health insurance Marketplace, also known as the Health Benefit Exchange.
Washington Healthplanfinder is the Marketplace serving Washington residents. This notice provides basic information
about the Marketplace as well as PEBB benefits offered by your employer and is intended to assist you in evaluating
options for you and your family.
1. What is the Health Insurance Marketplace?
Under the ACA, every state must have a health insurance Marketplace to help people buy health insurance. The
Marketplace offers assistance to help you find and compare medical health insurance options offered by private
companies. The Marketplace will also help you find out if you qualify for premium tax credits or other financial
assistance.
2. When does open enrollment begin?
Open enrollment for the Marketplace begins October 1, 2013 for coverage starting as early as January 1, 2014.
3. Can I save money on my health insurance premiums in the Marketplace?
You may qualify to save money and lower your monthly premium, but only if you are not eligible for PEBB medical
plan enrollment as an employee. The amount of premium savings in the Marketplace depends on your household
income.
4. Does being eligible for an employer contribution for PEBB medical coverage affect eligibility for premium
savings through the Healthplanfinder?
Yes.
● Employees eligible for employer contribution:
All eligible state employees receive an employer contribution for PEBB medical plan enrollment and are not
allowed to waive PEBB medical coverage to enroll in coverage through the Marketplace. All or a portion of this
contribution may be excluded from income for Federal and State income tax purposes. These employees should
remain enrolled in their PEBB medical plan.
State employees who are eligible to receive an employer contribution cannot use the employer contribution to
purchase coverage through the Marketplace, and will not be eligible for a premium tax credit if they purchase
coverage through the Marketplace.
However, if the cost of a PEBB health plan to cover you (and not any other members of your family) is more than
9.5% of your household income for the year, or does not meet the “minimum value” standard set by the ACA, you
may be eligible for a tax credit or other financial assistance.
An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed
benefit costs covered by the plan is no less than 60 percent of
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Application for Employment Packet Part-Time Coaching or Stipend (Wenatchee Valley College)

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Completed 27 July 2020

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