Employee: Complete All Unshaded Areas (Please Print)

1 PAF

New Hire Form

Employee: Complete all unshaded areas (please print).

ACTIONS From (MM/DD/YYYY)

DESCRIPTION OF ACTION New Hire Student Hire CrHrs Volunteer Hire

Primary Position #

Primary Position Title

Employee Group --Non-resident alien? yes no Federal Employee

PERSONAL DATA (IT0002)

Last name______Name at birth ______

First name______Middle initial______(no period)

Known as (Nick Name)______SSN______Birth date ______/______/______Gender  Male  Female

ORGANIZATIONAL ASSIGNMENT (IT0001) sets up employee relationship to entire University organization

Benefits %: % for 12mo% for 9/10mo Ret/Ancil Not eligible

CURRENT POSITIONS AT THE UNIVERSITY

PERMANENT HOME ADDRESS (IT0006) (no punctuation or dashes)

Spouse’s name (if applicable)______

1 ______

2 ______

City ______State ______Zip ______- _____

Telephone (______) ______E-mail ______

 I do not wish to have my home address information published in the University directory. (xdir)

CURRENT HOME ADDRESS (IT0006) (no punctuation or dashes)

c/o______

1 ______

2 ______

City ______State ______Zip ______- _____

Telephone (______) ______E-mail ______

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EMERGENCY CONTACT (IT0006) (no punctuation or dashes)

Name______

Telephone (______) ______E-mail ______

PLANNED WORKING TIME (IT0007) sets up employee relationship to his/her current University contract(s)

Positive time reporting Employment Percent (FTE) Contract length code: Leave plan code

BASIC PAY (IT0008) sets up employee relationship to payroll

COST DISTRIBUTION (IT9027) matches IT0008, for reporting purposes [Distribution: 01-wage]

PAID APPOINTMENTS (IT9001) overview of current paid positions for reporting purposes

UNPAID APPOINTMENTS (IT9001) overview of current unpaid positions for reporting purposes

BANK DETAILS (IT0009) Attach Bank deposit form

Change DEPT to HOME

TAX AREA (IT0207): NE

TAX WITHHOLDING W4 / W5 (IT0210) Attach Form W-4 (required for all new/returning) / Form W-5 (optional)

Completed by Payroll

RESIDENCE STATUS (I-9) (IT0094) C -Citizen N -Non-citizen A –Non-Resident Alien

Attach Form I-9 with photocopies of documentation (required for all new/returning)

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ADDITIONAL PERSONAL DATA (IT0077)

Ethnicity (select one)  Hispanic/Latino  Not Hispanic/Latino

Race (select multiple) American Indian/Alaskan Native  Asian  Black or African American

 Native Hawaiian or Other Pacific Islander  White  Unknown

Veteran statusDischarge Date: ______ Non Veteran  Special Disabled Veteran

 Vietnam Era Veteran  Other Protected Veteran  Recently Separated Veteran

 Armed Forces Service Medal Veteran  Disabled Veteran  Unknown

Military status Not applicable  Active National Guard

Medicare eligible  Yes  NoDisability  Yes  No Date disability determined ____/____/______

1For new faculty hired on Health Professions Appointments HP and HC are the same date.

EDUCATION (IT0022)Enter only highest and most recent.(not required for student workers)

Date of graduation ____/____/_____ Institution name (acronym preferred)______

Certificate/Degree ______Is this the highest possible degree in your field?  Yes  No

------(additional degrees, if any)

Date of graduation ____/____/_____ Institution name (acronym preferred)______

Certificate/Degree ______Is this the highest possible degree in your field?  Yes  No

EMPLOYEE SIGNATURE

______date______

ADDITIONAL COMMENTS OR EXCEPTIONS:

APPROVAL SIGNATURES:

______date______date______

AttachmentsAttachments

Form W-4 (required for all new/returning employees) / Form W-5 (optional)

Form I-9 with photocopies of documentation (required for all new/returning employees)

Bank deposit form

Correspondence and supportive documentation

Page 1 of 3Revised June 2011