New Account
Employee Master File
Change
Company #: ________________ Company Name: ___________________
Exempt
Employee #: ________________ Social Security: ____________________
Non-Exempt
Employee Name: ________________________________________________________________
Address: ______________________________________________ Phone: _________________
City: __________________________________________ State: _______
Zip: _____________
Date of Birth: ____________ Gender:
___________
Tax Form:
W2
1099______
Date of Hire: _____________ Term Date: ______________ Rehire Date: __________________
Cost Center 1: ___________ (i.e. Location, Department)
Cost Center 2: ________________
Cost Center 3: ___________ Cost Center 4: _____________ Cost Center 5: ________________
Work State: ________
Worker’s Comp Code: ___________
(if applicable)
Tax Filing Status:
Single
Married
Head of Household
# Federal Exemptions: ____________ Add’l/ Flat Federal Withholding $ ______
$ or %
# State Exemptions:
____________ Add’l/ Flat State Withholding
$ ______
$ or %
Exempt From:
FITW
OASDI
Medicare
SITW
SDI
Pay Frequency:
Weekly
Bi-Weekly
Semi-Monthly
Monthly
Base Pay Rate: $ _________ per
Hour / Pay Period
Rate 2: $ _________ per
Hour / Pay Period
Rate 3: $ _________ per
Hour / Pay Period
Auto-Pay:
Salary
Hours
# Hours ________
Fax Completed Form to Sales @ (415) 532 2539
Toll Free (877) 422-2824