Oregon New Hire Reporting Form - Department Of Justice Page 2
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2New Hire Reporting - continued
Employer Federal Identification Number (FEIN)
State Identification Number
Submission Date
Employee First Name
M.I.
Last Name
Social Security Number
Employee Address
Date of Birth *
Employee City
State
Zip Code
Date of Hire *
Employee First Name
M.I.
Last Name
Social Security Number
Employee Address
Date of Birth *
Employee City
State
Zip Code
Date of Hire *
Employee First Name
M.I.
Last Name
Social Security Number
Employee Address
Date of Birth *
Employee City
State
Zip Code
Date of Hire *
Employee First Name
M.I.
Last Name
Social Security Number
Employee Address
Date of Birth *
Employee City
State
Zip Code
Date of Hire *
Employee First Name
M.I.
Last Name
Social Security Number
Employee Address
Date of Birth *
Employee City
State
Zip Code
Date of Hire *
* Providing this optional data enhances our ability to perform services more efficiently
Page 2 of 2 - OREGON NEW HIRE REPORTING FORM
CSF 01 0580 (Rev. 04/23/03)
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