Employee Information Form
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1EMPLOYEE INFORMATION FORM
Section A – To be completed by Employee
Please fill out completely & clearly
Company Name:
Last Name:
First Name:
Middle Initial:
SS #:
Date of Birth:
Home Phone: (
)
Address:
Email:
City, State & Zip:
Resident Tax District:
Ethnic Origin:
Caucasian
African American
(for EEO purposes only)
Hispanic
Asian
Other
Gender:
Male
Female
Person to Contact in Case of Emergency:
Name:
Address:
Telephone:
Home: (
)
Work: (
)
Relationship to You:
*****************************************************************************************************************************
Section B – To be completed by Employer
Employee Hire Date:
Job Title:
Department
:
Workers Comp Code
:
(if applicable)
(if applicable)
Employee’s Work State
(Need state that employee physically works in for proper taxing)
Full Time/ Part Time:
Rate of Pay:
per
Withholding Status: (From Line # 5 on Form W-4)
Single
Married
Received Copy of Employee Handbook Acknowledgement Form:
If Applicable:
Deduction Type:
Deduction Amount:
Effective Date:
Deduction Type:
Deduction Amount:
Effective Date:
This Box for Company Use Only
Information above approved by: _________
W-4 ____ I-9____ ID ____ Direct Dep. ____
Initial
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Parent category: Business