CENTRAL OREGON COMMUNITY COLLEGE
EMPLOYEE PAYROLL INFORMATION
New employees must complete this form on the first day of
employment, along with a W-4 form and an I-9 Form (with proper I.D.)
NAME:
(Last) (First) (Middle)
TODAY’S DATE: ____________________
COCC ID #: 820__________________ Social Security Number:
MAILING ADDRESS:
(Street/PO Box) (City) (State) (Zip)
PERSONAL E-MAIL ADDRESS: ______________________________ HOME PHONE #:____________________
IN CASE OF EMERGENCY, NOTIFY: PHONE #:
MARITAL STATUS: Married Single
OREGON PERS MEMBER: Yes No
EMPLOYEE TYPE: Full-Time Part-Time Temp / Irregular Wage Work Study_______
STUDENT: Yes________ No__________ If yes, number of credit hours presently enrolled:_____________
JOB TITLE: DATE OF HIRE:
DEPARTMENT:
DATE OF BIRTH: GENDER: Male Female
ETHNIC ORIGIN: Do you consider yourself to be Hispanic/Latino? Yes _____No ______
Black or African American (1) American Indian/Alaskan Native (2)___________
White (5) Asian (7)
Native Hawaiian or Other Pacific Islander (8)
CITIZENSHIP: US Citizen/Resident (1): US Citizen NON-Resident (2):
Resident Alien (3): (Name and Country):
NON-Resident Alien (4): (Name and Country):
VETERAN: Yes No
TOBACCO QUESTION (As required by Moda Health Plan): How would you describe your tobacco habits? Currently Use____
Have not used in the last 12 months_____ Never Used _____
Mail Check: ____ Pick Up Check in BEC: __ ____
EMPLOYEE’S SIGNATURE:
Automatic Payroll Deposit: Yes No (If yes, attach a voided check here.)
PLEASE NOTE: Your first payroll check will not be automatically deposited due to bank set-up/processing.
DIRECT DEPOSIT IS NOT AVAILABLE TO STUDENTS
Rev. 02/10/14
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