Employee Record Sheet
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1EMPLOYEE RECORD SHEET
New Employee**
For New Hires and Changes
Employee Change
Effective date of change: _______________
Employer/Client Name _____________________________________________
SECTION 1: Employee Complete and Sign (please print clearly)
Employee Name ___________________________________ (as shown on SS card)
Social Security # _______________________
Employee Name Change (if applicable) ________________________________________________________(as shown on SS card)
Address ___________________________________________________________________________________________________
City __________________________________________________________ State _________________ Zip ___________________
Employee Personal E-mail Address ______________________________________________________________________________
Contact Phone Number _________________________________
Male
Female
Date of Birth _______________
Emergency Contact Name ____________________________ Relationship ___________ Contact Phone Number _______________
NEW EMPLOYEE ONLY: I certify that the information on this form and my employment application and/or resume is true, complete, and correct to the best of my
knowledge and belief. I understand that I may be required to successfully complete a medical exam for initial and continued employment. I further understand
that my employment is at will and agree that it is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any
time for any reason or no reason, without prior notice. Neither I nor the employer have agreed on any specific period of employment, nor any specific pay or
benefits unless otherwise set forth in a separate contract. I agree that all claims, disputes and controversies between and among employees and any employee
and employer, administrative employer, all agents, or any other person shall be exclusively and finally settled through the Alternate Dispute Resolution process.
I understand the requirements of this position and acknowledge I am able to perform all essential job functions with or without reasonable accommodations.
Employee Signature: _____________________________________________________________________ Date ________________
SECTION 2: Employer Complete and Sign (please print clearly)
**New Employee Begin Date: ________________
Client Original Hire Date _______________
Job Title / Position: _______________________________ Department __________ Work State __________ W/C Code __________
Employee Type:
Payroll Frequency:
Schedule:
Semi-Monthly
Regular
Weekly
Part-time
On Call
Full-time
Monthly
Seasonal
Temporary
Bi-Weekly
Scheduled Hours per Pay Period: _______
No (exempt from overtime)
Yes (Hourly)
Is employee eligible for overtime pay according to Fair Labor Standards Act?
Hourly $ _________ per hour
Salary (exempt from OT) $ __________
per pay period or
per year
Pay Type/Rate:
Piecework
Commission
Other Allowances Per Pay Period _______________________________________________________________________________
Leave of Absence
Effective Date __________________
Return to Work Date _________________
Reason for Leave of Absence: _________________________________________________________________________________
Additional Comments: ________________________________________________________________________________________
Employer/Client Signature _________________________________________________________________ Date _______________
** In order to process payroll, this form must be submitted to ERM with a completed and signed Form W-4, Form I-9, Applicable State Withholding/Labor Forms,
Alternate Dispute Resolution Agreement (ADR), and Work Permit (where applicable).
Revision date 11/11/2015
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Parent category: Business