Employee Registration Form

Employment Registration Form

Worksite Location

Business Name:

Hire Date:

Start Date:

Personal Information

First Name:

Last Name:

Middle Initial:

Maiden/Former Name(s):

Social Security Number: --

Confirm Social Security Number: --

Date of Birth:

Gender:

Driver's License:

State:

Expiration Date:

Contact Information

Email:

Primary Phone:

Alternate Phone:

Street:

AptNum:

City:

State:

Zip:

Emergency Contact

Name:

Relation to You:

Phone:

Tax Information Marital Status: Single Married Married, but withhold at higher Single rate.

W-4 Allowances:

Additional Withholding (Federal):

Additional Withholding (State):

Citizenship Information Citizenship Status:

A citizen of the United States

A noncitizen national of the United States

A lawful permanent resident

An alien authorized to work until the expiration date listed below.

Alien Registration Number/USCIS Number:

Expiration of Authorized Alien Status Date:

Form I-94 Admission Number:

Foreign Passport Number:

Country of Issuance:

TERMS OF ACCEPTANCE and SIGNATURE

I, the applicant for employment, warrant the truthfulness of the information provided in this application.

Electronic Signature:

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.