OFFICE OF STUDENT MEDIA
PAID EMPLOYEE INFORMATION FORM
(Monthly or Hourly)
STUDENT INFORMATION
First Name ______________________
Middle Name ___________________
Last Name ________________________
CWID ________________________
SSN _______________________
Email _____________________________
LOCAL INFORMATION
Address __________________________________________________________________
City __________________________
State _____________ Zip Code _____________
Home Phone _________________________
Cell Number _______________________
PERMENANT INFORMATION
Address __________________________________________________________________
City __________________________
State _____________ Zip Code _____________
Home Phone _________________________
PERSONAL INFORMATION
Birth Date _____________________
Marital Status ____________________
If married, spouse’s name ___________________________________________
Emergency Contact ____________________________ Emergency Contact Relation ______________________________
Emergency Contact Number _____________________ Alternate Contact Number ________________________________
Major _________________________
Expected Graduate Term _________________
EMPLOYMENT INFORMATION
Department _______________________________________
Position ______________________________________
State Date _____________________ End Date ___________________ Monthly Salary* __________________________
*Monthly salary based on academic and/or publication calendar.
(
Wage _______________________
For Hourly employees only)
Are you currently employed by another UA Office? ___________
If so, what department _________________________
How many hours? ____________
_______________________________________
_________________________
OSM Office
Employee Signature
Date (mm/dd/yyyy)
Use Only
PA Complete
_______________________________________
_________________________
Total $ Amount
Supervisor Signature
Date (mm/dd/yyyy)
OSM Rep