Employee Status Information Hire/Change Form - County of Pulaski, Indiana

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EMPLOYEE STATUS INFORMATION HIRE/CHANGE FORM
COUNTY OF PULASKI, INDIANA
AN EQUAL OPPORTUNITY EMPLOYER
IMPORTANT NOTICE: PLEASE SUBMIT THIS INFORMATION AS SOON AS POSSIBLE TO THE AUDITOR'S OFFICE FOR
PROCESSING WITH YOUR OTHER NECESSARY PAPERWORK (W-4, WH-4, PERF, INSURANCE, 1-9, COPY OF ID,
DIRECT DEPOSIT FORM) *** IF THIS IS A CHANGE OF INFORMATION, PLEASE FILL IN ONLY WHAT NEEDS
CHANGED AND SIGN AND DATE. THANK YOU.
Employee Name:
SSN#:_______________________
___________________________________________
Address:
___________________________________________
___________________________________________
County of Residence:_________________ Birthdate:______________ Phone #____________
Sex: Male ___ Female____
Marital Status: Married______________ Single________
Department:__________________________
Full/Part Time/Seasonal:_______________
Position Title:_________________________
Appropriation Number:________________
(per Salary Ordinance to completed by Auditor's Office)
Date of Hire or Change:________________
Hourly Rate:________________________
(per Salary Ordinance to be completed by Dept. Head)
DEPENDENT INFORMATION (SPOUSE AND ALL CHILDREN INCLUDING STEP CHILDREN)
NAME:
RELATIONSHIP:
DATE OF BIRTH:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Pulaski County Personnel Policies Handbook Form
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1
EMPLOYEE STATUS INFORMATION HIRE/CHANGE FORM
COUNTY OF PULASKI, INDIANA
AN EQUAL OPPORTUNITY EMPLOYER
IMPORTANT NOTICE: PLEASE SUBMIT THIS INFORMATION AS SOON AS POSSIBLE TO THE AUDITOR'S OFFICE FOR
PROCESSING WITH YOUR OTHER NECESSARY PAPERWORK (W-4, WH-4, PERF, INSURANCE, 1-9, COPY OF ID,
DIRECT DEPOSIT FORM) *** IF THIS IS A CHANGE OF INFORMATION, PLEASE FILL IN ONLY WHAT NEEDS
CHANGED AND SIGN AND DATE. THANK YOU.
Employee Name:
SSN#:_______________________
___________________________________________
Address:
___________________________________________
___________________________________________
County of Residence:_________________ Birthdate:______________ Phone #____________
Sex: Male ___ Female____
Marital Status: Married______________ Single________
Department:__________________________
Full/Part Time/Seasonal:_______________
Position Title:_________________________
Appropriation Number:________________
(per Salary Ordinance to completed by Auditor's Office)
Date of Hire or Change:________________
Hourly Rate:________________________
(per Salary Ordinance to be completed by Dept. Head)
DEPENDENT INFORMATION (SPOUSE AND ALL CHILDREN INCLUDING STEP CHILDREN)
NAME:
RELATIONSHIP:
DATE OF BIRTH:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Pulaski County Personnel Policies Handbook Form
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______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________
FULL TIME HIRES COMPLETE THE FOLLOWING.
PART TIME/SEASONAL HIRES MAY SKIP TO BOTTOM, SIGN AND DATE.
SHERIFF RETIREMENT OR PERF: STATES ON HIRE DATE. APPLICATION RECEIVED: YES ___ NO__
INSURANCE: BEGINS THE FIRST OF THE NEXT MONTH FOLLOWING YOUR 1ST 60 DAYS OF FULL
TIME EMPLOYMENT. RECEIVED NECESSARY PAPERWORK? YES ____ NO_____
I AM AWARE MEDICAL DEDUCTIONS ARE PRETAXED UNLESS I NOTIFY THE PAYROLL CLERK TO
DO OTHERWISE. PLEASE INITIAL: ______________
OTHER DEDUCTIONS MAY BE AVAILABLE. CHECK WITH THE AUDTIOR'S OFFICE FOR AVAILABLE
PROGRAMS PAYABLE THROUGH WAGE DEDUCTIONS. THESE CAN BE ADDED AT A LATER DATE.
EMPLOYEE'S SIGNATURE:
DATE:
______________________________________________
_____________________
DEPARTMENT HEAD SIGNATURE:
DATE:
______________________________________________
_____________________
Pulaski County Personnel Policies Handbook Form
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