Employee Record Sheet For New Hires

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For New Hires
Employer/Client Name __________________________________________
SECTION 1: Employee Complete and Sign (please print clearly)
Employee Name _________________________________
Social Security # ___________________
(as shown on SSN card)
Employee Name Change (if applicable) ____________________________________________________
(as shown on SS card)
Address _________________________________________________________________________________________
City ____________________________________________________________ State ____________ Zip ____________
Employee Personal E-mail Address ____________________________________________________________________
Date of Birth _______________
Contact Phone Number _______________________________
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 ________
Payroll Frequency:
Employee Type:
On Call
Scheduled Hours per Pay Period:
No (exempt from overtime)
Is emloyee eligible for overtime pay according to Fair Labor Standards Act?
Yes (Hourly)
Pay Type/Rate:
per year
per pay period or
Hourly $ _________ per hour
Salary (exempt from OT) $
Other Allowances Per Pay Period _____________________________________________________________________
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).
(800) 574-4668


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Parent category: Business