Fillable Application for Employment Packet Part-Time Faculty (Wenatchee Valley College)

Fill Online, Printable, Fillable, Blank Application for Employment Packet Part-Time Faculty (Wenatchee Valley College) Form

Use Fill to complete blank online WENATCHEE VALLEY COLLEGE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Application for Employment Packet Part-Time Faculty (Wenatchee Valley College)

On average this form takes 59 minutes to complete

The Application for Employment Packet Part-Time Faculty (Wenatchee Valley College) form is 21 pages long and contains:

  • 0 signatures
  • 50 check-boxes
  • 212 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Wenatchee Valley College

BROWSE WENATCHEE VALLEY COLLEGE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
(Please print single sided) WENATCHEE VALLEY COLLEGE
Application for Employment Packet
Part-Time Faculty
This application packet should ONLY be filled out if an individual has been offered a job as a part-time
faculty member.
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 Faculty
For liberal arts and sciences faculty:
Transcripts required (unofficial are fine)
For vocational faculty:
Copies of transcripts and/or current certification in area of specialization required
Copies of professional development certificates indicating current training in area of specialization
are appreciated but not required
For continuing education and basic skills faculty: the department will contact you if there is other
documents required.
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-3 (must be signed)
The worksheet has been completed with the assumption the new employee is not teaching for another
college concurrently or is not transferring from another college to WVC. 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)
Completed application materials must be received by the college before the individual can begin work.
Occasionally, however, immediate needs of the department require some flexing of this policy. In such a case, the
materials must be completed within three days of beginning work.
Questions regarding any part of the application process can be directed to human resources at 509-682-6440.
WENATCHEE VALLEY COLLEGE
Application for Employment
As
sistance will be made available in the application and pre-employment screening processes for
applicants with disabilities who request such assistance in advance
1300 Fi
fth 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:
Part-Time Faculty
EDUCATION Check the following diploma/degrees you have earned:
AA/AAS Bachelor's Master's Doctorate High 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.
In adherence to provisions of the Immigration Reform and Control Act, Wenatchee Valley College hires only United States
citizens and aliens authorized to work in the United States. As a condition of employment, new employees must provide
acceptable proof of identity and employment eligibility within three days of initial hire.
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.
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 Coordinator, Wenatchi Hall 2133, (509) 682-6854, TTY/TTD: Dial
711, sas@wvc.edu. Revised 1/20 tm
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
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
https://www.irs.gov/pub/irs-pdf/fw4.pdf[1/24/2020 11:31:53 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.
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
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
N
Decision
No
Employee Name:
Employee ID:
Not needed at this time
PEBB Benefit Eligibility
A-3 (Worksheet B): Completed by the employer and provided to the employee
Newly hired faculty
EMPLOYEE ELIGIBILITY NOTIFICATION
1. Stacking Hours Across Employers (WAC 182-12-114 (3)(b))
Enter a
Y or N
Faculty has informed you that:
Employee Email Address: (optional)
2. Eligibility Calculator
Enter the anticipated percentage of full-time for each quarter or semester. Include the anticipated percentage
of faculty hours from other higher education institutions in the Other Institutions row.
Exclude any hours, standby hours, and any temporary increase in work hours, of 6 months or less, caused by
training or emergencies that have not been or are not anticipated to be part of the faculty's regular work
schedule or pattern. Employing agencies must request the PEBB Program's approval to include temporary
training or emergency hours in determining eligibility.
Describe any excluded hours:
They are working as faculty at more than one institution of higher education.
If "Yes," include hours from all faculty workloads when determining eligibility.
(Faculty workloads may only be stacked with other faculty workloads to establish or maintain eligibility).
Quarter Review
Fall
Winter
Spring
Summer
Your Institution:
Other Institutions:
Total
3. Requirements for Eligibility (WAC 182-12-114 (3)(a)(i))
Enter
Y or N
Employer anticipates the faculty will work:
a. Half-time or more (include faculty hours from other institutions if stacking); and
b. For the entire instructional year or equivalent 9-month period.
4. Eligibility Decision
Semester Review
Fall
Spring
Summer
Your Institution:
Other Institutions:
Total
If the answer to all requirements is "YES", the faculty is benefits-eligible. Continue with #5 of this
worksheet.
If the answer to any of the requirements is "NO", the faculty is not benefits-eligible at this time.
Skip to #9 of this worksheet. Routinely monitor the faculty's' eligible work hours on the B-2
worksheet to establish eligibility.
Revised 12/2019
Date
Date


Due Date
7. New Employee Resources to Enroll in PEBB Benefits
The following resources are available for newly eligible faculty about PEBB benefits:
ŸŸŸPEBB website
www.hca.wa.gov/public-employee-benefits/employees/how-enroll
The PEBB Employee Enrollment Guide (which includes enrollment forms)
5. Date of Eligibility (WAC 182-12-114 (3)(a)(i))
Faculty is eligible from the date of employment. This is typically the first day of work.
6. Coverage Begins: (WAC 182-12-114 (3)(c)(i))
8. Form Submission Dates: (WAC 182-08-197 (1)(a))
Insurance is effective the first day of the month following the day the faculty becomes eligible (see
section 5 above). If the faculty becomes eligible on the first working day of the month, then
benefits begin on that 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.
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).
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.
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.
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:
www.metlife.com/wshca
Auto or home insurance may be applied for at any time with Liberty Mutual.
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 account 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
https://www.hca.wa.gov/employee-retiree-benefits/public-employees/auto-and-home-insurance
https://www.hca.wa.gov/public-employee-benefits/employees/dependent-verification
Revised 12/2019
Date
Date
Stacking: Faculty may establish eligibility and maintain the employer contribution toward PEBB insurance coverage by working as
faculty for more than one institution of higher education. Faculty workloads may only be stacked with other faculty workloads to
establish eligibility under WAC 182-12-114(3) or maintain eligibility as described in WAC 182-12-131(3). A faculty becomes eligible
through stacking when they meet the requirements for eligibility as described in #3 above. When a faculty works for more than one
institution of higher education, the faculty must notify their employing agencies that they work at more than one institution and may
be eligible through stacking (WAC 182-12-114 (3)(b)).
www.hca.wa.gov/about-hca/file-appeal-pebb
Place a signed copy in the employee's file and provide a copy of the Employee Eligibility Notification to the employee.
Faculty Signature
WVC/686
9. Signature and Date: To be reviewed and signed by the employee and employer
• 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)).
• 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 at www.hca.wa.gov/about-hca/file-appeal-pebb)
Agency Representative Signature
Agency/Sub Agency
Summer or off-quarter/semester coverage: All benefits-eligible faculty (eligible as described in WAC 182-12-114 (3)(a) and (b))
who work an average of half-time or more throughout the entire instructional year or equivalent nine-month period and work each
quarter/semester of the instructional year or equivalent nine-month period are eligible for the employer contribution toward summer
or off-quarter/semester PEBB insurance coverage (WAC 182-12-131 (3)(c)).
Two-year averaging: All benefits-eligible faculty (eligible as described in WAC 182-12-114(3)(a) and (b)) who worked an average
of half-time or more in each of the two preceding academic years are potentially eligible to receive uninterrupted employer
contribution toward PEBB insurance coverage. "Academic year" means summer, fall, winter, and spring quarters or summer, fall,
and spring semesters and begins with summer quarter/semester. In order to be eligible for the employer contribution through two-
year averaging, the faculty must provide written notification of their potential eligibility to their employing agency or agencies within
the deadlines established by the employing agency or agencies (WAC 182-12-131 (3)(d)).
Faculty who lose eligibility for the employer contribution: All benefits-eligible faculty (eligible as described in WAC 182-12-114
(3)(a) and (b)) who lose eligibility for the employer contribution will regain it if they return to a faculty position where it is anticipated
that they will work half-time or more for the quarter/semester no later than the twelfth month after the month in which they lost
eligibility for the employer contribution. The employer contribution begins on the first day of the month in which the quarter/semester
begins (WAC 182-12-131 (3)(e)).
Revised 12/2019
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 such costs.
● Employees not eligible for employer contribution:
Employees who are not eligible for the employer contribution for PEBB medical plan enrollment should consider
applying for health benefits in the new Marketplace as they may qualify for a premium tax credit or other financial
assistance. Your payments for coverage through the Marketplace are made on an after-tax basis.
5. How do I get additional information about the Marketplace?
The Marketplace simplifies your search for health coverage by gathering the options available in your area in one
place. You can compare plans based on price, benefits, quality, and other features important to you before you make
a choice.
Visit www.healthcare.gov (with a live chat option) or also get help by phone, or in person.
Call 1-800-318-2596, 24 hours a day, 7 days a week. (TTY: 1-855-889-4325).
6. How do I contact the Washington Healthplanfinder?
For Washington state residents, Washington Healthplanfinder can help you evaluate Marketplace coverage options
and possible premium savings online, by phone, or in person:
Washington Healthplanfinder
810 Jefferson Street S.E.
Olympia, WA 98501
360-688-7700
www.wahealthplanfinder.org
7. How do I get more information about PEBB benefits?
For more information about PEBB health plans offered by your employer, please check the Certificate of Coverage for
your plan, or contact your benefits office.
You can also find complete information about PEBB benefits at the PEBB website: www.hca.wa.gov/pebb
Information about PEBB health coverage offered by your employer
This section contains information about any health coverage offered by your employer. If you decide to complete an
application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to
correspond to the Marketplace application.
3. Employer name
Wenatchee Valley College
4. Employer Identification Number (EIN)
91-081775
5. Employer address
1300 Fifth Street
6. Employer phone number
509.682.6440
7. City
Wenatchee
8. State
WA
9. ZIP code
98801
10. Who can we contact about employee health coverage at this job?
Amy Smith or Tim Marker
11. Phone number (if different from above)
12. Email address
asmith@wvc.edu or tmarker@wvc.edu
Here is some basic information about health coverage offered by Wenatchee Valley College:
• As your employer, we offer a health plan to:
All employees.
Some employees.
Eligible employees are described in Washington Administrative Code 182-12-114:
(1)(a) An employee is eligible if he or she works an average of at least eighty hours per month and works for at least
eight hours in each month for more than six consecutive months.
(i)Upon employment: An employee is eligible from the date of employment if the employing agency anticipates the
employee will work according to the criteria in (a) of this subsection.
(2)(a) Seasonal employees are eligible if he or she works an average of at least eighty hours per month and works
for at least eight hours in each month of the season. A season is any recurring, cyclical period of work at a specific
time of year that lasts three to eleven months.
(b) Determining eligibility.
(i) Upon employment: A seasonal employee is eligible from the date of employment if the employing agency
anticipates that he or she will work according to the criteria in (a) of this subsection.
(ii) Upon revision of anticipated work pattern. If an employing agency revises an employee's anticipated work hours
such that the employee meets the eligibility criteria in (a) of this subsection, the employee becomes eligible when the
revision is made.
(iii) Based on work pattern. An employee who is determined to be ineligible for benefits, but later works an average of
at least eighty hours per month and works for at least eight hours in each month and works for more than six
consecutive months, becomes eligible the first of the month following a six-month averaging period.
(c) Stacking of hours. As long as the work is within one state agency, employees may "stack" or combine hours
worked in more than one position or job to establish eligibility and maintain the employer contribution toward
insurance coverage. Employees must notify their employing agency if they believe they are eligible through stacking.
Stacking includes work situations in which:
(i) The employee works two or more positions or jobs at the same time (concurrent stacking);
(ii) The employee moves from one position or job to another (consecutive stacking); or
(iii) The employee combines hours from a seasonal position or job to hours from a nonseasonal position or job. An
employee who establishes eligibility by stacking hours from a seasonal position or job with hours from a nonseasonal
position or job shall maintain the employer contribution toward insurance coverage under WAC 182-12-131(1).
(3)(a) Faculty "Half-time" means one-half of the full-time academic workload as determined by each institution, except
that half-time for community and technical college faculty employees is governed by RCW 28B.50.489.
Note: A change to the definition of full time, for community and technical college faculty, based on a collective
bargaining agreement may affect an employee’s eligibility for PEBB benefits. If eligibility is lost, COBRA coverage is
available as described in WAC 182-12-146.
(i) Upon employment: Faculty who the employing agency anticipates will work half-time or more for the entire
instructional year, or equivalent nine-month period, are eligible from the date of employment.
(ii) For faculty hired on quarter/semester to quarter/semester basis: Faculty who the employing agency anticipates
will not work for the entire instructional year, or equivalent nine-month period, are eligible at the beginning of the
second consecutive quarter or semester of employment in which he or she is anticipated to work, or has actually
worked, half-time or more. Spring and fall are considered consecutive quarters/semesters when first establishing
eligibility for faculty that work less than half-time during the summer quarter/semester.
(iii) Upon revision of anticipated work pattern: Faculty who receive additional workload after the beginning of the
anticipated work period (quarter, semester, or instructional year), such that their workload meets the eligibility criteria
of (a)(i) or (ii) of this subsection become eligible when the revision is made.
(b) Stacking. Faculty may establish eligibility and maintain the employer contribution toward insurance coverage by
working as faculty for more than one institution of higher education. Faculty workloads may only be stacked with
other faculty workloads to establish eligibility under this section or maintain eligibility under WAC 182-12-131(3).
When a faculty works for more than one institution of higher education, the faculty must notify his or her employing
agencies that he or she works at more than one institution and may be eligible through stacking
(4)(a) Elected and full-time appointed officials of the legislative and executive branches of state government are
eligible for PEBB benefits on the date his or her term begins. All other elected and full-time appointed officials of the
legislative and executive branches of state government are eligible on the date their terms begin or the date they take
the oath of office, whichever occurs first.
(5)(a) Justices and judges are eligible for PEBB benefits on the date they take the oath of office.
• With respect to dependents:
We do offer coverage.
We do not offer coverage.
Eligible dependents are described in Washington Administrative Code 182-12-260:
(1) Lawful spouse.
(2) Domestic partner. (a) Effective January 1, 2010, a state registered domestic partner, as defined in RCW
26.60.020(1). (b) A domestic partner who was qualified under PEBB eligibility criteria as a domestic partner before
January 1, 2010, and was continuously enrolled under the subscriber in a PEBB health plan or life insurance.
(3) Children. Children are eligible up to age twenty-six except as described in subsection (i) of this section. Children
are defined as the subscriber's:
(a) Children as defined in RCW 26.26.101 establishment of parent-child relationship;
(b) Biological children;
(c) Stepchildren. The stepchild’s relationship to a subscriber (and eligibility as a PEBB dependent) ends, for purposes
of this rule, on the same date the subscriber’s legal relationship with the spouse or domestic partner ends through
divorce, annulment, dissolution, termination, or death;
(d) Legally adopted children;
(e) Children for whom the subscriber has assumed a legal obligation for total or partial support in anticipation of
adoption of the child;
(f) Children of the subscriber's state registered domestic partner;
(g) Children specified in a court order or divorce decree;
(h) Extended dependents in the legal custody or legal guardianship of the subscriber, the subscriber's spouse, or
subscriber's state registered domestic partner. The legal responsibility is demonstrated by a valid court order and the
child's official residence with the custodian or guardian. "Children" does not include foster children for whom support
payments are made to the subscriber through the state department of social and health services foster care program;
and
(i) Children of any age with a disability. Effective January 1, 2011, children of any age with a disability, mental
illness, or intellectual or other developmental disability, who are incapable of self-support, provided such condition
occurs before age twenty-six. Periodic certification is required.
(4) Parents.
(a) Parents covered under PEBB medical before July 1, 1990, may continue enrollment on a self-pay basis as long
as:
(i) The parent maintains continuous enrollment in PEBB medical;
(ii) The parent qualifies under the Internal Revenue Code as a dependent of the subscriber;
(iii) The subscriber continues enrollment in PEBB insurance coverage; and
(iv) The parent is not covered by any other group medical plan.
(b) Parents eligible under this subsection may be enrolled with a different health plan than that selected by the
subscriber. Parents may not add additional dependents to their insurance coverage.
If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended
to be affordable, based on employee wages.
Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through
the Marketplace. The Marketplace will use your household income, along with other factors, to determine whether
you may be eligible for a premium discount. If, for example, your wages vary from week to week (perhaps you are an
hourly employee or you work on a commission basis), if you are newly employed mid-year, or if you have other
income losses, you may still qualify for a premium discount.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Application for Employment Packet Part-Time Faculty (Wenatchee Valley College)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 27 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document