State Of Alaska Employment Status Form 2000
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1STATE OF ALASKA
Department of Administration
____________________________
_______________________
___________________________
LAST NAME
FIRST NAME
SOCIAL SECURITY NUMBER
State of Alaska Employment Status:
Have you ever been employed by the State of Alaska?
_____Yes
_____No
If so, which Department? _______________Separation Date?________
Have you been laid off from a permanent position within the last two years? _____Yes
_____No
Are you employed by the State now?
_____Yes
_____No
If so, which Department? ______________________________
Nepotism
List any relatives you have working for the Department of Administration:
Name(s)
Relationship(s)
Division(s)
__________________
_______________________
_____________________
__________________
_______________________
_____________________
_______________________________________________ _________________________
Employee Signature
Date
Attn: Human Resources, after input into AKPAY, cut off and discard the EEO Data
Attn: Human Resources, after input into AKPAY, cut off and discard the EEO Data
Attn: Human Resources, after input into AKPAY, cut off and discard the EEO Data
Attn: Human Resources, after input into AKPAY, cut off and discard the EEO Data
-------------------------------------------------------------------------------------------------------------
Equal Employment Opportunity Data
*CIRCLE ONE LETTER ONLY*
Alaska
American
Asian/Pacific
Spanish
Native
Indian
Islander
Black
Surname
White
Female
D
A
B
C
E
H
Male
P
K
L
O
S
T
ALASKA NATIVE:
Eskimo, Aleut, Tlingit, Haida, Athabascan, etc.
AMERICAN INDIAN:
Crow, Sioux, Honi, Apache, Seminole, Navajo, Shoshone, etc.
ASIAN/PACIFIC ISLANDER: Includes persons of Japanese, Chinese, Korean, Filipino, Polynesian decent.
BLACK:
Includes persons of African descent as well as Jamaican, Trinidadian and West
Indian.
SPANISH SURNAME:
Includes maiden names and all persons of Mexican, Puerto Rican, Cuban, Latin
American or Spanish descent.
WHITE:
Includes persons of Indo-European descent, including Pakistani and East-Indian.
Revised: December 19, 2000
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