Date:

Social Security #

Employee #

Gender

□ Male   □ Female

Job Category

Date of Birth

□ Rehire   □ New Hire

Employment Date

□ Exempt □ Non exempt

Name:                       

Legal Address:

Mailing Address:

Check Mailing Address:

Department Name (City, State, Zip Code required)

Emergency Contact Name:                                                Relationship:                                   Number:

Home Phone #

Review/ Raise Date

Annual Salary: $

Salary Date

New Hire □

Hourly Rate

Pay Period Hours

Hours

Salary Grade

Location Code

Location Code Description

Requisition Number

□ Addition Replacement    □ Person Replaced

Previous Hire Date

Previous Termination Date

Term Code

COMMENTS:

Required Signatures

PAYROLL USE ONLY

Supervisor                                                 Date

Department VP                                         Date  

Human Resources                                   Date

Human resources                                     Date