NEW EMPLOYEE FORM
Please fax completed form to your Payroll Specialist.
Client Information
Client Name Client #
Effective Date Date Sent to PrimePay
/ / / /
Employee Information
Name (Last, First, Middle) Social Security Number
- -
Street Address City State Zip Code
Birth Date Hire Date Rehire Date
/ / / / / /
Marital Status Gender # of Exemptions (Federal) # of Exemptions (State)
□ Single □ Married □ Male □ Female
Rates and Frequency
Hourly Pay Rates (System will automatically calculate for overtime, use this for separate base rates)
Primary Rate 2nd Rate 3rd Rate
Salary Per Pay Department # Department Name
Pay Frequency (please check one) Weekly Bi-Weekly Semi-Monthly Monthly
Withholdings
State Tax Code SUI State Local Tax
Special Withholding (Provide dollar amount or percentage below)
□ Additional □ Override Applied to: □ Federal □ State □ Local
Scheduled Deductions (If applicable) Scheduled Earnings (If applicable)
Code Amount or % Frequency Other Code Earnings Amount Frequency
Vacation or Sick Accruals? (If applicable) Yes No Rate ________________ Frequency _________________
Special Instructions
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