New Hire Reporting Form 2012
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1Pennsylvania New Hire Reporting Program
COMMONWEALTH OF PENNSYLVANIA
New Hire Reporting Form
Center for Workforce Information & Analysis
Department of Labor & Industry
REQUIRED EMPLOYER INFORMATION:
REQUIRED EMPLOYEE INFORMATION:
(Please type or print LEGIBLY in blue or black ink ONLY)
(Please type or print LEGIBLY in blue or black ink ONLY)
ONE EMPLOYEE PER BOX
Employer FEIN:
Employee Social Security Number
Employer Name:
Legal Name (First)
(Middle)
(Last)
Employer Address (Street, City, State, Zip):
PO Box’s are not acceptable
Street Address (Post Office Box is not acceptable) Apartment Number (if available)
Employer Contact Name:
Zip Code
City
State
Employer Contact Phone Number:
Date of Hire (MM/DD/YYYY)
Date of Birth (MM/DD/YYYY)
(Must be within 3 years of current date)
Employer Contact Fax Number:
ONE EMPLOYEE PER BOX
Employer Contact Email:
Employee Social Security Number
Please fax this form to:
Legal Name (First)
(Middle)
(Last)
866-PAHIRES (866-748-4473) (TOLL FREE)
Or 717-657-HIRE (717-657-4473) (Local)
Street Address (Post Office Box is not acceptable) Apartment Number (if available)
Or mail this form to:
Commonwealth of Pennsylvania
Zip Code
City
State
New Hire Reporting Program
P.O. Box 69400
Date of Hire (MM/DD/YYYY)
Date of Birth (MM/DD/YYYY)
Harrisburg, PA 17106-9400
(Must be within 3 years of current date)
ONE EMPLOYEE PER BOX
Questions?
Contact New Hire Customer Service at 888-PAHIRES (888-724-4737)
Employee Social Security Number
Or by email at: RA-LI-CWDS-NewHire@pa.gov
Legal Name (First)
(Middle)
(Last)
This form may be duplicated as needed
Save time and postage costs.
Street Address (Post Office Box is not acceptable) Apartment Number (if available)
Online reporting is fast, free and paperless.
Zip Code
City
State
For more information about how to get started, please visit
Date of Hire (MM/DD/YYYY)
Date of Birth (MM/DD/YYYY)
(Must be within 3 years of current date)
Or contact our customer service at 888-PAHIRES (888-724-4737)
New Hire Reporting: Lending a Hand to Pennsylvania's Children
CWIA-25 06-12 (Page 2)
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Parent category: Business