___________________________________________
___________________________________________
Employee Name
(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)
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.
