Dhhs Equal Employment Opportunity Institute Form
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1DHHS EQUAL EMPLOYMENT OPPORTUNITY INSTITUTE (EEOI)
PARTICIPANT REGISTRATION FORM
TODAY’S DATE: ________________
NOTE: Form must be filled out completely and sent to your Training Coordinator.
Date and Location of EEOI you wish to attend (DHHS classes only):
st
1
Choice:
Date: _______________Location: ____________________________
nd
2
Choice:
Date: _______________Location: ____________________________
ENROLLEE DATA
Name: __________________________________________________________
Job Title: ____________________________________Pay Grade: __________
Last 4 digits of Social Security No. __________ Race: _____ Sex: ____ Age: _____
Division: _________________________ Facility/Agency: ______________________
Work Phone: ________________________
Fax #: __________________________
E-Mail Address: _________________________________________________________
Eligibility/Promotion/New Hire Date: ________________________________________
(Date hired or promoted into supervisory position)
EPA (exempt) ____ or SPA (subject) ____County Where Employed________________
Supervisor’s Name: _______________________________________________________
Workplace Address: ______________________________________________________
Mail Service Center (MSC) Address: _________________________________________
Training Coordinator’s Use Only:
Is an accommodation needed for this enrollee to participate in the EEOI? If so, please indicate the type of accommodation:
Accommodation: ____________________________________________________________________________________
Training Coordinators – Please fax completed registration forms:
919-715-9238 Attention:
Gloria Overby
Training Coordinator’s Signature : _______________________________________Date _____________
Telephone: ________________________________ E-Mail Address: ____________________________
Revised 02//22/2011
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