Employee Information Submission

Please fill out the information below.

Contact your manager if you have any questions. Refer to Federal and State W-4 for tax withholdings.

Company Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

SSN

Phone

(###)

###

####

Date of Birth

Gender

Start Date

Pay Type

Pay Amount

Department

Job Title

Federal Status

Multiple Jobs and/or Spouse Works

Refer to W-4

Federal Dependent Allowance $

Refer to W-4

Hawaii State Status

Hawaii State Allowances

Bank Routing Number

Bank Account Number

Bank Account Type