Employee Status Information Hire/change Form printable pdf download

Employee Status Information Hire/change Form

EMPLOYEE STATUS INFORMATION HIRE/CHANGE FORM

COUNTY OF PULASKI, INDIANA

AN EQUAL OPPORTUNITY EMPLOYER

IMPORTANT NOTICE: PLEASE SUBMIT THIS INFORMATION AS SOON AS POSSIBLE TO THE AUDITOR'S OFFICE FOR

PROCESSING WITH YOUR OTHER NECESSARY PAPERWORK (W-4, WH-4, PERF, INSURANCE, 1-9, COPY OF ID,

DIRECT DEPOSIT FORM) *** IF THIS IS A CHANGE OF INFORMATION, PLEASE FILL IN ONLY WHAT NEEDS

CHANGED AND SIGN AND DATE. THANK YOU.

Employee Name:

SSN#:_______________________

___________________________________________

Address:

___________________________________________

County of Residence:_________________ Birthdate:______________ Phone #____________

Sex: Male ___ Female____

Marital Status: Married______________ Single________

Department:__________________________

Full/Part Time/Seasonal:_______________

Position Title:_________________________

Appropriation Number:________________

(per Salary Ordinance to completed by Auditor's Office)

Date of Hire or Change:________________

Hourly Rate:________________________

(per Salary Ordinance to be completed by Dept. Head)

DEPENDENT INFORMATION (SPOUSE AND ALL CHILDREN INCLUDING STEP CHILDREN)

NAME:

RELATIONSHIP:

DATE OF BIRTH:

______________________________________________________________________________

Pulaski County Personnel Policies Handbook Form

Employee Status Information Hire/change Form