*PRI*
Accord Human Resources
Payroll Information
®
EMPLOYEE INFORMATION
Name:____________________________________________________ Social Security___________________________
(Nombre) Last/Apellido
First/Nombre
Middle/Inicial
(Seguro Social)
Address:_________________________________________________________________________________________
(Dirección) Street/Numero y Calle
Apartment Number/Numero del apartamento
City/Ciudad
State/Estado
Z
ip/Código Postal
Date of Birth:_________________________________ Home Telephone:______________________________________
(Fecha De Nacimiento) Month/Mes Day/Dia Year/Año (Teléfono)
Area Code/Numero del Area
Number/Numero
Email Address:___________________________________________
(Dirección de Correo Electrónico)
Reasonable attempts will be made to forward all known wages to you. If we are unable to locate you, a $20 service fee will be deducted from any wages held by
Accord, unless prohibited by law, and such wages will be forwarded to the appropriate government authority.
Las tentativas razonables serán hechas para adelantarle todos sueldos conocidos. En caso de no localizarlo una compensación de $20 será descontado por servicios
de cualquier sueldo que usted tiene con Accord, a menos que sea prohibido por la ley, y tales sueldos serán adelantados a la autoridad apropiada del gobierno.
NATURE OF ACTION
Effective Date:______________________________________________ Original Hire Date: _____________________
Month
Day
Year
Hour
Month
Day
New Employment
Regular (More than 30 hrs. per week.)
Part-time (Less than 30 hrs. per week.) Part-time (Less than 20 hrs. per week.)
Temporary Seasonal
Rehire: Previous location
_ Name/Address/Phone Change
Transfer
Leave of absence
Compensation change; Next review date:
_ Return from leave of absence
Year
In what state does this employee work?
PAYROLL DATA
Client Name:___________________________________
Employee Title:_______________________________
Client Number:_________________________________
Dept.:_______________________________________
Pay Rate: $_______________ Per hour
Per ________
Pay Frequency: (choose one) Weekly Bi-weekly Semi-monthly Monthly
(choose one) Hourly
Classification: (check one) Exempt
Salary Piecework Commission
Non-Exempt
Workers’ Compensation Code:__________________________________
EEO Job Category: ________
1. Executives/Sr. Level
Managers
2.Professionals
3.Technicians
4.Sales
5. Administrative Support
6. Craft Workers (skilled)
7. Operatives (semi-skilled)
8.Laborers/Helpers
(unskilled)
9. Service Workers
16. First/Mid-Level Managers
Reason for Action (must be completed): __________________________________________________________________
Benefit Eligibility: ____ Benefit Group: # __________
____ Not Eligible
Paid Time Off:
____ Not Eligible
____ PTO Group: # __________
Approved By:____________________________________________________ Date:_____________________________
Accord Designated On-Site Supervisor
(05/11)
0
