F00014 Registration/Emergency Contact for ETC/ETT Appointments at Headquarters

Instructions:

Welcome to the World Bank Group HR Forms Instructions page.

This form filler tool is designed to assist you in electronically entering your data and printing a paper form with a unique barcode corresponding to your entered data. Once you've completed your answers and printed the form, you'll need to submit it either by email or in person, depending on the form type. Please note that the data you enter is directly captured in the form's unique barcode, so it's important that you do not make any handwritten changes, corrections, or additions to the data or to the form after it has been printed. Doing so may result in data errors and processing delays.

In case you notice any errors after printing your form, or if you've left a field blank, we recommend starting over and completing a new form. It's also important to remember that your information is not saved by the form filler and can no longer be accessed after you print it. Therefore, please be extra careful in reviewing your answers, as it is impossible to make any corrections after the form is printed.

Each form will take approximately ten minutes to complete. Please ensure you have the needed documents such as passport to extract information that may be required in some fields. Do not close the forms until they are ready for a download. Partially filled forms cannot be saved to be completed later. If you need further assistance, please contact. Thank you!

Information on Completing the Form

IMPORTANT: To determine eligibility for benefits, the following documents are required for yourself and each dependent:

a) For non-U.S. individuals: copies of photo and bio pages of passport, U.S. visa (such as G4) or Green Card, & I-94 card (front & back);

b) Copy of valid Employment Authorization if you will start employment with an F1, J1, L2 or A1/A2 dependent visa.

c) Copies of birth certificates for yourself and any listed dependents;

d) Adoption documents for legal adoptions;

e) Copies of certificate / proof of marriage. Domestic partnerships must be approved by the HR Operations in accordance with the domestic Partner policy. A separate package for registering your Domestic partnership will be provided.

Please return these documents to the HR Operations (Select one transmittal format, and submit only once):

E-Mail at hroperations@worldbank.org
Fax +1 (202) 522-7026
Interoffice mail MSN G2-202

Need Help?

If you are experiencing any issues, please contact HR Operations via email: hroperations@worldbank.org or phone 202-473-2222 or 5220+32222.

Revision 25 Apr 2023

Hidden BC

Spouse/Domestic Partner Information

Spouse/Domestic Partner Name*

Relationship*

Spouse

Domestic Partner

Date of Birth*

SSN

Gender*

Male

Female

City of Birth*

Country of Birth*

Nationality (Indicate if multiple)*

If non-US, current US Visa & Alien Registration # (if applicable) - provide copy

PR, list A#:

Other, specify:

Children Eligible for Medical Insurance

You can extend Medical Insurance Plan coverage for a non-dependent child. Coverage for eligible children continues through the last day of the month in which the child reaches age 26, unless documentation has been provided to show that the child(ren) became physically or mentally handicapped before s/he reached age 25.

Please complete all sections for each child eligible for medical insurance. You will not receive other benefits (including, but not limited to, relocation, Mobility Premium, Dependency Allowance, Life & Accident Insurance) for this child(ren).

A child eligible for Medical Insurance is:

(1) Age 25 or younger on the staff member's first day of employment unless the child was physically or mentally handicapped while unmarried, dependent, and aged 24 or younger, AND

(2) your biological child, legally adopted child, or the biological or legally-adopted child of your current domestic partner or spouse registered with the World Bank Group.

Child Name (Last, First, Middle)*

Gender*

Male

Female

Date of Birth*

City of Birth*

Country of Birth*

Nationality (Indicate if multiple)*

SSN

If non-US, current US Visa & Alien Registration # (if applicable) - provide copy

PR, list A#:

Other, specify:

Child is:*

My Natural Child

My Adopted Child

My Stepchild

Other Household Information

Other Household Members who are on a Bank-sponsored G4/G5 visa.

Name*

Gender*

Male

Female

Relationship*

Date of Birth*

Visa*

Expiration Date of I-94*

City of Birth*

Country of Birth*

Nationality (Indicate if multiple)*

Home Mailing Address in new Duty Station - Please fill out even if a temporary address.

Enrollment into the Medical Insurance Plan may be delayed without a local mailing address at the new duty station.

Street*

City, State, Postal or Zip Code*

Home phone*

Cell phone*

Emergency Contact

Name*

Relationship*

Street*

City, State and Pincode*

Country*

Phone*

Certification and Signature

I, the undersigned, certify that the information provided by me is complete and true. I understand that World Bank Group benefits are subject to audit, and I consent to and authorize the release of any information needed for benefits administration to the World Bank Group or their representatives. I understand any misstatements regarding the use of benefits may result in disciplinary measures per Staff Rules 3.00 or 8.01.

I understand that in the event of a conflict between this form and the Staff Rules, the Staff Rules will prevail.

Staff Member's Signature

Date

After filling this document, you must sign and date it before returning this document to the World Bank Group. Please ensure ALL information in the submission form is complete and accurate before printing the form. This will generate your form(s) as a PDF file. Review the file for accuracy and completeness. If there is an error, please start a new form.