HTML Preview Employee Datasheet page number 1.
EMPLOYEE DATA SHEET
COMPANY NAME: _________________________________________EMPLOYEE # (if applicable) ________
EMPLOYEE NAME: LAST__________________________FIRST________________________MI ______
ADDRESS________________________________________________________
CITY _________________________________STATE __________ ZIP ___________________
SSN: _______________________________ DOB __________________ □ Male □ Female
HIRE DATE _____________________ EMAIL __________________________________________
Job Code (SOC)_________________LOCATION ________________ DEPARTMENT__________________
PAY FREQUENCY: (circle one) WEEKLY BI-WEEKLY SEMI-MONTHLY MONTHLY QUARTERLY
SALARY PER PAY PERIOD $____________________
HOURLY RATE(S) (IF APPLICABLE) rate 1:$________ rate 2:$________ rate 3: $________per hour
CONTRACT EMPLOYEE (1099) CHECK HERE ______ Amount per pay period $_______________
TAX WITHOLDIING STATUS – Employees Only (transfer from W-4 / L-4):
Federal Tax Status: □ Married □ Single ______ # of Allowances Withhold Extra $ ____
State Tax Status: □ Married □ Single ______ # of Exemptions______ # of Dependents Withhold Extra $____
DEDUCTIONS / REIMBURSMENTS: (attach court orders for child support)
Ded./ Reimb.Name __________________ Amount per check $_____________ Pre-tax □ Yes □ No
Ded./ Reimb.Name __________________ Amount per check $_____________ Pre-tax □ Yes □ No
DIRECT DEPOSIT:
(attach voided check or bank authorization)
□ checking □ savings Account #___________________Routing # _________________% or $______
□ checking □ savings Account #___________________Routing # _________________% or $______
I _________________________________authorize Payroll Rx to initiate credit entries for payroll to the above account(s). I also
authorize debt entries or adjustments in the event of an error in connection with my payroll. This is to remain in effect until I cancel
this authorization in writing.
Signature:___________________________________________ Date: __________________