EMPLOYEE PROFILE

Client Name / LifeStar Emergency Services, LLC / Client Number
Company Name (if different) / Company Number

Employee #______EFFECTIVE DATE:

SSN______

Last Name ______First Name ______Middle Initial ______

Address ______City ______State ___ Zip ______

Date of Hire ______Date of Birth ______Date of Termination ______

Gender Male Female Status Active  Terminated Type Full Time  Part Time  1099 Contractor

Rate of Pay $ ______per  Hour or  Pay Period

Division______Branch ______Department ______

TAX INFORMATION:Withholding State ______SUIState ______County______City ______

FederalStateLocal

Marital Status Single  Single

 Married  Married

# Exemptions______

Additional Amt or Pct______ Amt  %______ Amt  %______ Amt  %

Special Taxing Considerations ______

EARNINGS / DEDUCTIONS:

TypeAmount ($) or Percent (%)Start DateStop Date

______ Amt  %______

______ Amt  %______

______ Amt  %______

______ Amt  %______

______ Amt  %______

TIME OFF ACCRUALS(Enter rates, usage, and balance in hours):

Accrual RateUsed (Taken)New Balance

Vacation_____0______

Sick_____0______

Personal / PTO_____0______

EMPLOYEE DIRECT DEPOSIT ADD/CHANGE

EMPLOYEEINSTRUCTIONS:

Please provide your Name and the last four digits of the SSN for verification purposes. Enter your bank account information and select which proof documentation will accompany this registration form. Be sure to sign this form at the bottom and retain a copy for your records.

For the first pay cycle after registration, you will receive a live check while your bank account information is being verified in the required pre-note process.

EMPLOYEE IDENTIFICATION: / EMPLOYER USE ONLY:
Employee Name: / Company Name: / LifeStar Emergency Services
Last 4 Digits SSN: / Client #
EMPLOYEE BANK ACCOUNT #1 / ADD CHANGE DELETE
Bank Name / Account Type / Checking Savings Money Market
ABA Routing # / Account Number
Deposit Options: / All Net Pay / Required Proof: / Voided Check (no deposit slips)
Flat Dollar Amount = / $.00 / Bank letter or specification sheet
Percentage of Net = / %
EMPLOYEE BANK ACCOUNT #2 / ADD CHANGE DELETE
Bank Name / Account Type / Checking Savings Money Market
ABA Routing # / Account Number
Deposit Options: / All Net Pay / Required Proof: / Voided Check (no deposit slips)
Flat Dollar Amount = / $.00 / Bank letter or specification sheet
Percentage of Net = / %
Employee Signature / Date
My signature above authorizes my employer to make deposits into the above named account(s). I also herewith authorize my employer to initiate either paper or paperless debits for sums due to my employer for erroneous credits or deposits made to my bank account.

Employee Profile

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