*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)