Student/part-Time/temporary Employee Information Sheet
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1FRESNO STATE PROGRAMS FOR CHILDREN, INC.
STUDENT/PART-TIME/TEMPORARY EMPLOYEE INFORMATION SHEET
PLEASE CHECK THE CORRECT BOX(ES):
NEW HIRE
PART-TIME
STUDENT AT FRESNO STATE
CHANGE
Address
Fresno State Faculty
_________ #of units enrolled for:
Cost Center
RE-HIRE
Fresno State Staff
Fall
Spring
Summer
Pay Increase
Non-Fresno State Employee
Other: _______________
TO BE COMPLETED BY EMPLOYEE
Name:
Social Security Number:
-
-
Phone Number:
Mailing Address: __________________________________________________________________________________________
(
) ____________
Street
Apt. #
City
State
Zip Code
Fresno State Email Address: ______________________________________________@mail.fresnostate.edu
Date of Birth:
Married
Single
Male
Female
Have you worked or are you currently working for the Association, Foundation, or Ag Foundation?
Yes
No
If yes, Last Day Worked: ________________ Department: ________________________________________________
EMERGENCY CONTACT INFORMATION
In case of emergency, notify:
Name: _________________________________
Relationship: _______________________
Phone: _________________________
ACKNOWLEDGEMENTS
I have received and acknowledge the following forms as part of the new hire packet:
Nature of Employment Agreement
Injury and Illness Prevention Program
PFC Arbitration Agreement
PFC Handbook (available on )
AB 469 Rate and Payday Notification
W4 Form
Drug Free Workplace Policy
I-9 Employment Eligibility Form
Dated: _____________________________________
Employee Signature: _____________________________________
TO BE COMPLETED BY SUPERVISOR
Cost Center/Obj. Code/Subsidiary:
Date of Hire or Re-hire:
Mail Stop:
Pay Rate:
Position Title:
$
Is it likely that this position would have contact with minors (individuals under the age of 18)?
Yes
No
Confidential Data Access?
Is driving a requirement for this position?
Supervisory Responsibility?
Yes
No
Yes
No
Yes
No
Nepotism: “Related employees are not permitted to work in job positions in which a conflict of interest could arise or in a direct supervisory
relationship.” To my knowledge, this hire does not violate the Association Nepotism policy. _______Employee Initials _______Supervisor Initials
PAY INCREASE *Please attach justification and AB 469
Reason for Increase:
Current Hourly Rate:
New Hourly Rate:
Effective Date:
AUTHORIZATION REQUIRED
Employee Signature
Date
Supervisor Signature
Date
Approving Manager Signature
Date
OFFICE USE ONLY
Aux ID:
Date:
Entered by:
Paid Sick Leave:
Date:
Reviewed by:
Date:
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