___________________________________________
___________________________________________
Employee Name
Fresno State ID
Disability Status
(Item 125)
Please indicate your status by checking one of the following:
A. Disabled Veteran, Vietnam era B. Special Disabled Veteran, Not of Vietnam era
C. Other Eligible Veteran D. NONE of the above
If boxes A, B, or C are checked you MUST complete Disability Factor Code
: ________________
(See Disability Factor Code Listing Posted in Payroll)
Alien Status
If U.S. Citizen check box to the right, if NOT then complete boxes below.
(825/X-CCY)
U.S. Citizen
X - Visa Type:
F Visa type (Non-citizen student Visa)
Permanent resident (OOR) Non-resident (OON) _______(MO/YR) exp date
J Visa type (Non-citizen Exchange Visitor D/S enter as 9999
Z Visa type All other types of non-citizen visas (e.g. H-1B, TN) __________________
CC See Chart for Country Codes
Y Tax Resident Code:
R Resident N Non-resident
____ / ______ZZZZ Work Authorization end date = (MM/YY)
Drug Free Workplace Policy
The Drug Free Workplace Act of 1988, effective March 18, 1989, requires that the University certify that it will
provide a drug-free workplace.
In compliance with the Act, employees are hereby notified that the unlawful manufacture, distribution, dispensing,
possession or use of a controlled substance is prohibited in our workplace. Violation of this policy may result in
disciplinary action, including but not limited to suspension and/or termination or a requirement to participate in an
approved drug abuse assistance or rehabilitation program.
Employee must be aware that as a condition of employment they will abide by the terms of this policy and will
notify the University of any criminal drug statute conviction for a violation occurring in the workplace within five
days after such conviction. The University must notify the federal agency involved of the conviction within 10
days of receiving such a notice. Within 30 days, the University will initiate the appropriate personnel action or
require satisfactory participation in an approved drug abuse assistance or rehabilitation program.
I hereby certify that I have read, understand and will abide by the conditions of this policy.
______________________________________ ______/_____/__________ _________________
Signature Social Security Number Date
Please complete information on reverse side.
__________________________________________
__________________________________________
___________________________________________________________________
___________________________________________________________________
Employee Name
Fresno State ID
Ethnic Code
___________ Ethnic Code from below.
African
Filipino
G
Puerto Rican
B
Aleut
O
Guamaria
n/Chamorro
R
Samoan
Q
American Indian
H
Hawaiian
Vietnamese
Cambodian
U
Indo
-
European (Caucasian)
-
E
Other Asian
Caucasian
-
Japanese
I
Other Hispanic
D
Chinese
J
Korean
K
Other Pacific Islander
T
Cuban
C
Laotian
V
Other Non
-
White
-
X
Eskimo
-
N
Mexican/Mexican
-
American/Chicano
-
A
Resident Address different from W
-
2 Address
Complete this section ONLY IF your residence address is different from your mailing
or W-2 address completed on the Employee Action Request (EAR) form section F.
Resident Address
City, State and Zip
Please note:
Physical presentation of your Social Security Card (issued by the Social Security Administration) MUST be
used for establishing a new employee. Copies or any other record cannot be used.
References:
? 7/1/98 MEMORANDUM to Theresa Hines, Office of the Chancellor from Linda MacAllister,
University Counsel; Subject: Presentation of Social Security Card.
? 4/15/91 SALARIES, WAGES and BENEFTIS audit recommendation, Board of Trustees, CSU
Employees must be directed to the SSA Office to initiate a request for duplicate SSA card for presentation.
Should this be required, a RECEIPT of the request for a duplicate card must be requested during the SSA
request to be used temporarily in processing the new hire.
Please complete information on reverse side.