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					                A                             B                 C        D                         E
 1 ENTER INFORMATION BELOW                                                                Revised 2/16/2010 - ACW
 2            Today's Date: 8/11/2012                               I-9 Hire Date:
 3               Entered By:                                           Position #:
 4                                                                           Org #:
 5                                                                Epaf Hire Date:
 6    Employee Information
 7               First Name:                                            Birthdate:
 8            Middle Name:                                          Middle Initial:
 9               Last Name:                                        Maiden Name:
10          Employee SSN:                                        Preferred Name:
11               MyWSU ID:
12           Street Address:                                         Apartment #:
13                      CITY:                                             County:
14                   STATE:                                         Dept. Phone #:
15                        ZIP:                                   University Dept:
16           Email Address:                                         Campus Box:
17               Telephone:                                            Extension:
18
19    Employer Information                                                            This sheet must be fully
20                    Phone:                                                             completed and the
21                       Fax:                                                         student must deliver it to
22                   Contact:                                                         HR along with their new
23                       Title:                                                            hire paperwork.
24             Campus Box:
25                                                                                      Contacts:
26 Business Name/Address: Wichita State University                       Forms Questions: Margene Webster x6149
27                              1845 Fairmount, Wichita, KS 67260                  Tech Questions: Dale Catlin x6150
28
29                                                                                          Rev: dcc 07/11/2012
                                          STUDENT EMPLOYEE INFORMATION                                                           Revised: 09/02/2009
                                     Wichita State University -- Office of Human Resources
Name:
          Last                                           First                       MI             Maiden

Preferred Name:
Street Address                                                                                      Apt #:
City:                                   State:                      Zip Code:                       County:
Phone:                                             MyWSU#:                                                        Birthday:
Work #:                                        Campus Box No:                                  University Dept.
Do you want the following information printed in the campus directory? (circle)                     Name           ____YES                 ____NO
Have you worked for the State of Kansas before?                                                     Address        ____YES                 ____NO
                                        YES                         NO                              Phone          ____YES                 ____NO
If yes, list each agency and employment dates:




Marital Status (check one)                                                           Citizen Status (check one)
                                                                                                                                 Resident Alien
          Single                                         Divorced                                   Citizen                      Permanent

          Married                                        Common-Law                                 Naturalized                  Alien Temporary


          Separated                                      Widowed
                                                                                       SPOUSE'S PHONE:
 SPOUSE'S NAME:                                                                                   Work:
                       Last                              First

                                       EEO/AFFIRMATIVE ACTION UPDATE
RACE/ETHNIC IDENTIFICATION                           DISABLED VETERAN?
1. Are you Hispanic or Latino?                                       YES                                                         NO
                      YES                   NO
2. Please check all that apply to you:               MILITARY STATUS
                       Asian                                                         None                         Special Diabled Vet - 30%

                       American Indian/Alaskan Native                                Vietnam                      Special Disabled Vietnam Vet - 30%

                       Native Hawaiian/Pacific Islander                              Other                        Disabled Vet - less than 30%

                       Black or African American                                     Retired                      Disabled Vietnam Vet - less than 30%

                       White                                                         Active Reserve
GENDER
                       Male                              Female
EDUCATION
                       less than high school graduate               2-year college degree                         Master's degree

                       High school graduate (or equiv)              3 year college                                Doctorate degree

                       Technical school                             4-year college                                Post doctorate

                       1-year college                               Bachelor's degree

                       2-year college                               Some graduate school
IN CASE OF EMERGENCY, PLEASE CONTACT:
NAME:                                                                                        RELATIONSHIP:

ADDRESS:
                       Street                            City                        State                        Zip Code




TELEPHONE (work): _________________________ TELEPHONE (home): _________________________
                                    EMERGENCY CONTACT INFORMATION

EMPLOYEE:                                                                   MyWSU ID:
                                                                        Effective Date:



                     IN CASE OF EMERGENCY, PLEASE CONTACT:

Name: __________________________________________              Family:                     or Friend:


Street Address: _____________________________________________________________________________

City: ___________________________________          State: ____________ Zip Code: ______________________

Country: ___________________________________________________________________________________

Primary Contact Telephone#: ________________________                     Other #: _______________________



Name: __________________________________________              Family:                     or Friend:


Street Address: _____________________________________________________________________________

City: ___________________________________          State: ____________ Zip Code: ______________________

Country: ___________________________________________________________________________________

Primary Contact Telephone#: ________________________                     Other #: _______________________



Name: __________________________________________              Family:                     or Friend:


Street Address: _____________________________________________________________________________

City: ___________________________________          State: ____________ Zip Code: ______________________

Country: ___________________________________________________________________________________

Primary Contact Telephone#: ________________________                     Other #: _______________________



Name: __________________________________________              Family:                     or Friend:


Street Address: _____________________________________________________________________________

City: ___________________________________          State: ____________ Zip Code: ______________________

Country: ___________________________________________________________________________________

Primary Contact Telephone#: ________________________                     Other #: _______________________


This information will not be disclosed to other employees or organizations – it is for the sole purpose of
emergency contacts in the event of accident/illness. Please send your updated emergency contact information to
the Office of Human Resources, Campus Box #15, or fax to 316-978-3201 for inclusion in your personnel file.
                             NEW HIRE DIRECTORY                         INFORMATION                    888-219-7801 EXT 100
                             PO BOX 3510 TOPEKA, KS                                                    IN TOPEKA 296-5025
                             66601-3510
                                                                        FAX                            888-219-7798
KANSAS DEPARTMENT OF HUMAN RESOURCES                                                                   IN TOPEKA 291-3423

                                           NEW HIRE REPORT
SECTION ONE
                                           EMPLOYEE CERTIFICATION
PRINT OR TYPE


         NAME                                                                     SSN


    ADDRESS                                                                                                   Apt.
                STREET



                CITY                                      STATE                         ZIP


ARE YOU CURRENTLY OR HAVE YOU BEEN ORDERED BY A COURT TO PAY CHILD SUPPORT?                   oYES          oNO
I CERTIFY UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF KANSAS THAT THE FOREGOING IS TRUE AND CORRECT.



____________________________________                                     ________________________________
DATE SIGNED                                MM-DD-YY                     EMPLOYEE'S SIGNATURE


SECTION TWO
                                           EMPLOYER CERTIFICATION
   EMPLOYER WICHITA STATE UNIVERSITY                              FEIN 48 - 6029925
                BUSINESS OR TRADE NAME                                  FEDERAL EMPLOYER'S ID NUMBER




    ADDRESS 1845 FAIRMOUNT
                STREET




                WICHITA                                   KS                            67260
                CITY                                      STATE                         ZIP



  TELEPHONE
                VOICE                                                   FAX




    CONTACT
                NAME                                                    TITLE


SECTION THREE
                                                REPORTING OPTIONS
IF THE EMPLOYEE ANSWERS YES TO THE CHILD SUPPORT QUESTION IN SECTION ONE, THIS REPORT MUST BE SUBMITTED TO THE ADDRESS OR FAX AT
THE TOP OF THIS REPORT WITHIN 20 DAYS OF HIRING, REHIRING OR RETURN TO WORK OF THE EMPLOYEE.
IF THE EMPLOYEE ANSWERS NO TO THE QUESTION, THIS REPORT MUST BE RETAINED. AT THE END OF THE QUARTER ALL NEW EMPLOYEES
ANSWERING YES AND NO MUST BE REPORTED ON THE QUARTERLY NEW HIRE SUMMARY, K-CNS 110.
INSTEAD OF COMPLETING THIS REPORT FOR EACH NEW EMPLOYEE TO DETERMINE IF THE EMPLOYEE IS SUBJECT TO A CHILD SUPPORT ORDER,
MPLOYERS MAY ELECT TO REPORT ALL NEWLY HIRED, REHIRD AND RETURNING EMPLOYEES WITHN 20 DAYS. IF YOU CHOOSE TO VOLUNTARILY
REPORT ALL EMPLOYEES WITHIN 20 DAYS, IT WILL BE UNNECESSARY TO FILE BOTH THIS REPORT, K-CNS 104, AND THE QUARTERLY NEW HIRE
SUMMARY, K-CNS 110.

EMPLOYERS MAY USE THE FEDERAL FORM W-4, EMPLOYEE'S WITHHOLDING ALLOWANCE CERTIFICATE TO
VOLUNTARILY REPORT ALL EMPLOYEES. THE EMPLOYER MUST COMPLETE BOXES 8 AND 10 ON THE W-4. COPIES
OF THE WITHHOLDING CERTIFICATE MUST BE SUBMITTED WITHIN 20 DAYS OF HIRE, REHIRE OR RETURN TO
WORK. EMPLOYEE INFORMATION IN BOXES 1 AND 2 MUST BE LEGIBLE AND COMPLETE.



K-CNS 104 (6-98)
    STUDENT CONSENT FOR INSPECTION AND/OR
            RELEASE OF INS FORM I-9


I authorize Wichita State University to permit inspection and/or release of
Immigration and Naturalization Service form I-9 to authorized officials of
the Immigration and Naturalization Service and/or the U.S. Department of
Labor. I understand that the release and/or inspection of Form I-9 is for
the purpose of determining whether I am employed or have been
employed by Wichita State University in accordance with the Immigration
Reform and Control Act of 1986, Pub. L. 99-603.




Printed Name of Student




Signature of Student                              Date
OATH/TAX FORM
Revised 12/2010
Form W-4                                                                                                                       OMB No. 1545-0010
Department of the Treasury                             Employee's Withholding Allowance Certificate
Internal Revenue Service                                                                                                       2012
1 First Name                                    M.I.           Last name                                                       2 Social Security #


Home address (number, street/rural route)                      Apt#              3 □Single oMarried oMarried, but withhold at higher Single rate
                                                                                Note: If married, but legally separated, or spouse is a
                                                                                nonresident alien, check the Single box.
City/Town                       State           Zip Code                         4 If your last name differs from that on your social security
                                                                                 card,check here ���� and call 1-800-772-1213 for a new card


5 Total number of allowances you are claiming (from line H above or from the worksheets if they apply)                          5

6 Additional amount, if any, you want withheld from each paycheck                                                               6 $

7 I claim exemption from withholding for 2011 and I certify that I meet BOTH of the following conditions for exemption:
   Last year I had a right to a refund of ALL Federal income tax withheld because I had NO tax liability; AND
   This year I expect a refund of ALL Federal income tax withheld because I expect to have NO tax liability.

If you meet both conditions, enter “EXEMPT” here                                                                                 7
Under penalties of perjury, I certify that I am entitled to the number of withholding allowances claimed on this certificate or entitled to claim exempt status.


Employee's Signature
                                                                                 _____     Date
(Form is not valid unless you sign it) ______________________________________________________ _________________________, 20____
    8 Employer’s name and address (Employer: Complete 8 and 10 only if sending to the IRS)              9 Office Code               10 Employer ID number

                 Wichita State University; 1845 Fairmount; Wichita, Kansas 67260-0038                     (optional)                     48-6029925

STATE OF KANSAS EMPLOYEE’S OATH

K.S.A. 75-4308 et seq requires that the following oath from K.S.A. 54-106, be signed by new employees before entering the
duties for employment and before funds for services may be disbursed:

I do solemnly swear (or affirm) that I will support the constitution of the United States and the constitution of the State of
Kansas, and faithfully discharge the duties of my office of employment. So help me God.



                                                                                 myWSU ID#



                                                                                 Employee's Signature
NOTARY USE ONLY:

State of Kansas
County of Sedgwick

Signed and sworn to (or affirmed) before me this __________ day of _____________________ 20_____ by ______________________________.

My commission expires ________________________, 20_____ .

Notary Public ________________________________________                             Notary Seal
_________________.
                          Statement Concerning Your Employment in a Job
                                  Not Covered by Social Security

Employee Name                                              Employee ID # (SSN)
                                                                  MyWSU ID #
Employer Name Wichita State University                          Employer ID # 48-6029925

Your earnings from this job are not covered under Social Security. When you retire, or if you become
disabled, you may receive a pension based on earnings from this job. If you do, and you are also entitled
to a benefit from Social Security based on either your own work or the work of your husband or wife, or
former husband or wife, your pension may affect the amount of the Social Security benefit you receive.
Your Medicare benefits, however, will not be affected. Under the Social Security law, there are two ways
your Social Security benefit amount may be affected.

Windfall Elimination Provision
Under the Windfall Elimination Provision, your Social Security retirement or disability benefit is figured
using a modified formula when you are also entitled to a pension from a job where you did not pay
Social Security tax. As a result, you will receive a lower Social Security benefit than if you were not
entitled to a pension from this job. For example, if you are age 62 in 2005, the maximum monthly
reduction in your Social Security benefit as a result of this provision is $313.50. This amount is updated
annually. This provision reduces, but does not totally eliminate, your Social Security benefit. For
additional information, please refer to Social Security Publication, “Windfall Elimination Provision.”

Government Pension Offset Provision
Under the Government Pension Offset Provision, any Social Security spouse or widow(er) benefit to
which you become entitled will be offset if you also receive a Federal, State or local government pension
based on work where you did not pay Social Security tax. The offset reduces the amount of your Social
Security spouse or widow(er) benefit by two-thirds of the amount of your pension.

For example, if you get a monthly pension of $600 based on earnings that are not covered under Social
Security, two-thirds of that amount, $400, is used to offset your Social Security spouse or widow(er)
benefit. If you are eligible for a $500 widow(er) benefit, you will receive $100 per month from Social
Security ($500 - $400=$100). Even if your pension is high enough to totally offset your spouse or
widow(er) Social Security benefit, you are still eligible for Medicare at age 65. For additional information,
please refer to Social Security Publication, “Government Pension Offset.”

Social Security publications and additional information, including information about exceptions to each
provision, are available at www.socialsecurity.gov. You may also call toll free 1-800-772-1213, or for the
deaf or hard of hearing call the TTY number 1-800-325-0778, or contact your local Social Security office.

I certify that I have received Form SSA-1945 that contains information about the possible effects
of the Windfall Elimination Provision and the Government Pension Offset Provision on my
potential future Social Security benefits.


Signature of Employee: ______________________________________ Date:




Form SSA-1945                                                                         Revised: 12/06
                                                  KANSAS
K-4                             EMPLOYEE’S WITHHOLDING ALLOWANCE CERTIFICATE
(9/07)

The following instructions will assist you in               had no tax liability; 2) Verify with KDOR that               filed with your employer; otherwise, your
completing the worksheet and K-4 form below.                this year you will receive a full refund of all              employer must withhold Kansas income tax
After you have completed the K-4 form,                      STATE income tax withheld because you will                   from your wages without exemption at the
detach it and give it to your employer. For                 have no tax liability.                                       “Single” allowance rate.
assistance with this form, call KDOR (Kansas                Notes: Your status of “Single” or “Joint” may                Head of household: Generally, you may
Department of Revenue) at 785-368-8222.                     differ from your status claimed on your                      claim head of household filing status on your
Purpose of the K-4 form: A completed                        Federal Form W-4. Claiming more than the                     tax return only if you are unmarried and
withholding allowance certificate will let your             proper amount may result in taxes owed                       pay more than 50% of the cost of keeping
employer know how much Kansas income tax                    filing your state income tax.                                up a home for yourself and for your
should be withheld from your pay on income                  Basic Instructions: If you are not exempt,                   dependent(s).
you earn from Kansas sources. Because your                  complete the Personal Allowances                             Nonwage income: If you have a large
tax situation may change, you may want to                   Worksheet below. The allowances claimed                      amount of nonwage Kansas source income,
refigure your withholding each year.                        on this form should not exceed that claimed                  such as interest or dividends, consider making
Exemption from withholding: To qualify for                  under “Exemptions” on your Kansas income                     estimated tax payment using form K-40ES,
exempt status you must, 1) Verify with KDOR                 tax return. To avoid owing taxes when you                    Estimated Tax for Individuals. Otherwise, you
that last year you had the right to a refund of             file, follow the suggested allowance rate                    may owe additional tax when filing your state
all STATE income tax withheld because you                   selection on line A below. This form must be                 income tax return.
                                    Personal Allowance Worksheet (Keep for your records)
A Allowance Rate
          If you are a single filer mark “Single”
          If you are married and your spouse has income mark “Single”
          If you are married and your spouse does not work mark “Joint”
                                                                                         o Single                    }                                             o Joint

B Enter “0” or “1” if you are married or single and no one else can claim you as a dependent (entering “0” may
             help you avoid having too little tax withheld) .............................................................................................................._______
                                                                                                                                                                      B
C Enter “0” or “1” if you are married and only have one job, and your spouse does not work (entering “0” may
                                                                                                                                                             C _______
             help you avoid having too little tax withheld) ..............................................................................................................
D Enter “1” if you will file head of household on your tax return (see conditions under “Head of household” above) … D _______
E Enter the number of dependents you will claim on your tax return. Do not claim yourself or your spouse or
             dependents that your spouse has already claimed on their form K-4. .....................................................                            E _______
F Enter “1” if you have at least $1,500 of child or dependant care expenses for which you plan to claim a credit and
             your household income is below $50,000 ............................................................................................                 F _______
G Add lines B through F and enter the total here .............................................................................................                   G _______
                           6Cut here and give this K-4 form to your employer. (Keep the top portion for your records.)
                                         Kansas Employee’s Withholding Allowance Certificate
 K-4
(9/07)                 Whether you are entitled to claim a certain number of allowances or exemptions from withholding is
                        subject to review by KDOR. Your employer may be required to send a copy of this form to KDOR.
1 First Name                                             M.I.                   Last Name                                                   2 Social Security #


Mailing Address                                                                 Apt #              3 Allowance Rate
                                                                                                           Mark the allowance rates selected in Line A above.
City or Town, State, and ZIP code
                                                                                                                          o Single                                 o Joint
4 Total number of allowances you are claiming (from line G above) .............................................................                              4
5 Enter any additional amount you want withheld from each paycheck (this is optional) .............................                                          5
6 I claim exemption from withholding. You must meet the conditions explained in the “Exemption from
         withholding” instructions above. If you meet those conditions, write “Exempt” on this line.                         6
         Note: KDOR will receive your federal W-2 forms for all years claimed Exempt.
Under penalties of perjury, I declare that I have examined this certificate and to the best of my knowledge and belief it is true, correct,
and complete.
SIGN
HERE                                                                                                                 DATE
7 Employer's Name and Address                                                                                        EIN (Employer ID Number)
    Wichita State University; 1845 Fairmount; Wichita KS 67260                                                            48-6029925
                            GLACIER NON RESIDENT ALIEN TAX
                                   Set-up Information


          Today’s Date:

          Social Security Number:

          My WSU ID:

Please use the name that is on your Social Security Card. Please print legibly.

          Name       (First):

                     (Middle):

                     (Last or Family):

Please use your Wichita.edu address or a address you use:

          E-mail Address:

          Phone Number:

                                    RETURN TO PAYROLL
                                     210 JARDINE HALL
                                      CAMPUS BOX 38
                                 If questions, call 978-3074


Payroll Use Only:

Entered by:

Date Entered:




Rev. 02/24/2009
                                                  State of Kansas
                                   SUBSTANCE ABUSE POLICY
                                               AFFIRMATION FORM

                                                Statement of Policy
Employees are the State of Kansas' most valuable resource and, therefore, their health and safety is a serious
concern. The State of Kansas will not tolerate substance abuse or use which imperils the health and well-being of
its employees or threatens its service to the public. Furthermore, employees have a right to work in an
environment free of substance abuse and with persons free from the effects of drug or alcohol abuse. It shall
therefore be the policy of the State of Kansas to maintain a workforce free of substance abuse.

A. Reporting to work or performing work for the state while impaired by or under the influence of controlled
substances or alcohol is prohibited.

B. The unlawful manufacture, distribution, dispensing, possession or use of a controlled substance is prohibited in
the workplace, or while the employee is on duty, official state business or stand-by duty.
C. Violation of such prohibitions by an employee is considered conduct detrimental to state service and may result
in a referral to the Employee Assistance Program or discipline in accordance with K.S.A. 75-2949d, or other
appropriate administrative regulations.

D. Employees are required by federal law to notify the employing state agency head in writing of his or her
conviction for a violation of a criminal drug statute occurring in the workplace no later than five calendar days after
such conviction.
      (1) An employee who is convicted of violating any criminal drug statute in such workplace situations as
stated above will be subject to discipline in accordance with K.S.A. 75-2949d, or other appropriate administrative
regulations.

       (2) A conviction means a finding of guilt (including a plea of nolo contendre) or the imposition of a sentence
by a judge or jury, or both, in any federal or state court.

E. Agencies that receive federal grants or contracts must, in turn, notify federal granting agencies in writing, within
ten calendar days of receiving notice from an employee or otherwise receiving actual notice of such conviction.
Employers of convicted employees must provide notice, including position title to every grant officer or other
designee on whose grant activity the convicted employee was working, unless the Federal agency has designated
a central point for the receipt of such notices. Notice shall include the identification number(s) of each affected
grant.

F. Employees will be given a copy of the Substance Abuse Policy. Employees will be informed that they must
abide by the terms of the policy as a condition of employment and of the consequences of any violation of such
policy.
Affirmation of Policy
As an employee for the State of Kansas, I affirm that I have read and understand the meaning of the above
Substance Abuse Policy. I am aware of the provisions of this policy which is mandated by the Federal Drug-Free
Workplace Act, and that a violation of this policy will result in disciplinary action as stated above.


NAME                                                                       MyWSU ID


71500-Wichita State University
Agency No. and Name:                                                       Position No.


(Signature of Employee)                                                                        Date



(Signature of Agency Representative)                                                           Date




Original to Agency                                                                                                DPS 417
Copy to Employee                                                                                            Rev.: 06/02/08
                                                 Americans with Disabilities (ADA) Status
                                                    and Request for Accomodations



Disability Status (please check all that apply)

                        Visual                              Physical
                        Hearing                             Learning
                        Speech                              Other (please list)




                            REQUEST FOR ACCOMMODATIONS

Wichita State University is an AA/ADA/EEO Employer. It is the policy of the University to provide equal
employment opportunity and advancement opportunities for all qualified persons, and to prohibit
discrimination in employment on the basis of race, color, religion, sex, age, national origin, disability,
marital status, sexual orientation, disabled veteran, or Vietnam Era veteran status.


Do you require any accommodations for the disabilities indicated above in order to perform the
essential functions of your job?

                                                            YES                      NO
If yes, explain:




If you need accommodations in order to perform your job as provided in the Americans with
Disabilities Act (ADA), your request will be forwarded to the Director of Disability Services
who will contact you.


             PRINTED NAME:

             myWSU ID #

             DEPARTMENT:


EMPLOYEE’S SIGNATURE                                                                 DATE


Revised: 06/2008
                                                               Payroll Deposit Form

o New Application         o Change of Bank           o Change of Account/Amount                  o Cancellation


Automatic deposits can now be split to more than one account. If more than one account is
listed, employee must designate percentage or amount of net pay to be deposited to each
account.

Primary Bank Information (Required)
One hundred percent (100%) of net pay will be deposited to primary bank less any deposits to other bank(s) as
listed below.
                                                        Routing #: ___________________
Bank Name: ______________________________________________________________________________

Account Number: ________________________________________ o Checking                                      o Savings


Bank Information                                     Priority #: __________
                                                        Routing #: ___________________
Bank Name: ______________________________________________________________________________

Account Number: ________________________________________ o Checking                                      o Savings

                                                                  Amount : $_______________ or _______ %


Bank Information                                     Priority #: __________
                                                        Routing #: ___________________
Bank Name: ______________________________________________________________________________

Account Number: ________________________________________ o Checking                                      o Savings

                                                                  Amount : $_______________ or _______ %


Employee Information
I authorize the State of Kansas/WSU to initiate accounting transactions to deposit my employee pay directly to the
account(s) indicated above and to correct any errors which may occur from these transactions. I also authorize the
Financial Institution to post these transactions to these accounts. This authorization is to remain in force until the State of
Kansas/WSU receives written notice from me to cancel or change this authorization.


Name (please print):

myWSU ID (required):


Home Address:
                                                                      Apt#                City              State       Zip Code:

Contact Phone # (home, cell or work):



Signature:                                                                          Date:

Attach on deposit slip or voided check for each account and return to the Payroll Office, Campus Box 38




                                                                                                                                    06/10

				
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