Phone: (607) 734-3491
O.M.S.
Employee
Name:_______________________________________________________
Mailing
Address:_______________________________________________________
City, State:___________________________________ Zip:____________________
Phone:_______________________________________
Social Security #:____________________ Marital Status:____________________
Exemptions: Federal:_____________________
State:_______________________
Additional Amounts:
$ _____________________ $
_______________________
Date of Hire:___________________ Male:______________ Female:__________
Rate of Pay:
$_________________
Hourly:____________ Salary:____________
Department:___________________________
Special
Info:____________________________________________________________
_______________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
*This is not a substitute
for the W-4. Please have employee complete a W-4 and keep on file*