Rehire? Yes
SECTION I: To be completed, in full, and signed by the Hiring Manager and Dean or Director. Incomplete or obsolete
forms will be returned and may cause delays in the hiring process.
Name of Employee: COCC ID Number:
Address: City: State: Zip:
Telephone: Email Address:
This individual has an application on file, is qualified for and has been approved to fill the following position:
Job Title: Department: Campus
Is this individual an active COCC Student or Retiree? Student Retiree No
Does this individual work anywhere else at the college during the current academic year? Yes No
If “Yes”, which department(s)? How many hours per week?
Which terms? Fall Winter Spring Summer
(Please note that the TOTAL # of hours/week than this employee works may make him/her eligible for overtime and/or medical
insurance under the Affordable Care Act, which could result in an additional cost to your account.)
Write a brief description in the space below OR Attach a job description (for all new positions):
The approximate length of this job assignment, starting with the first day (not to exceed one fiscal year 7/1 to 6/30):
Start Date: To: (approximate end date)
PLEASE NOTE: This employee must report to HR on the first day of employment with proper I-9
Identification, complete new hire paperwork, and be signed-off by HR to start working.
Is this person going to fill in for a regular/benefited employee?
Yes No If yes, who:
This person is to be paid: $ 10.25 per hour (minimum wage)
$ per hour. [See Irregular Wage Salary Schedule or
Contact Human Resources for appropriate wage.]
Status: Full-time (40 hrs/wk) Part-time ( hrs/wk) Months/Year:
The Account Number to which this hourly pay will be charged is:
Supervisor or Department Chair Date
Budget Administrator (Dean or Director) Date
SECTION II: Below is for HR office use only
Background check I-9 W-4 Application Payroll Information SafeColleges
User accounts needed: If Yes, please list (i.e. e-mail, N-drive home dept.) No
Human Resources Date
Original to Human Resources
(Revised 07/17)