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Payroll Status Information for Work-Study Employees

Employee ID #  (student ID)
Last Name
First Name
Suffix
Middle Name
Social Security Number - -
 
Permanent Home Address
Street
City
State  
Zip Code
County 
Country  
 
Phone 1 ( ) -
Phone 2 ( ) -
Cell Phone ( ) -
Email Address
 
Birth Date - -
Gender
Marital Status Single    Married     Widowed    Divorced
Name of Spouse
Contact Person(In case of emergency)
Phone # of Contact Person ( ) -
 
Dormitory Name(if applicable)
 

Would you like to authorize deposit of your earnings to your student tuition account?   
Yes No

 
Signature
Date

**NOTE:  Forms W-4, K-4 and I-9 along with 2 acceptable documents to verify eligibility to work (example; driver license, SS card, birth certificate, passport) must be submitted to HR before you will be allowed to work.