Pitzer College | Office of Human Resources and Payroll Services
Rev 08/2019 BG
Authorization Form to Hire a Pitzer Student Employee (Non-Work Study)
(Non-Work Study Only)
This form must be completed by the student and the supervisor and signed by the supervisor and the Area Vice President
Student Information | To be Completed By Student
Name: ____________________________________________
Preferred Name: ___________________________________
Student ID #: ______________________________________
Mailbox Number: __________________________________
Phone: ____________________________________________
Student Email: _____________________________________
Type of Hire: New Hire (First Pitzer Job) Re-Hire* (Additional Pitzer Job)
Position Information | To be Completed By Supervisor
Position: ___________________________________________
Department: ______________________________________
Work Location: ____________________________________
Timesheet Approver: _______________________________
Start Date: ________________________________________
End Date: _________________________________________
Hourly Rate: ______________
Hours Per Week*: ______________
Total Estimated Expenditure: ______________
Cost Center: _____________________ Function: ______________ Fund: ______________ Spend: ______________
*Benefits Eligibility: Student Employees become eligible for medical insurance benefits only IF they work at least 30 hours per week in a 12
month Measurement Period as defined by the Affordable Health Care Act. If so, they are then eligible on the first of the month 60 days
after said Measurement Period. The initial Measurement Period starts on the first of the month following the date of hire and runs for a
period of 12 months. Thereafter the ongoing Measurement Period will be from October 4 to October 3.
*Re-Hires: Individuals rehired within 4 weeks of their previous termination date will resume benefits eligibility IF they were eligible at the
time of their termination. If rehired later than 4 weeks but less than 26 weeks after their termination, they will resume benefits eligibility IF
they were eligible at the time of their termination AND their period of employment was greater than the break in service.
Budget Expenditure Authorization| To be Completed By Supervisor and Area Vice President
Supervisor: ______________________________________________________
Date: ________________________________
Area Vice President: _____________________________________________
Date: ________________________________
Submit Completed form to Human Resources for Processing
FOR HR OFFICE USE ONLY
Processed By: _________________________ Initials: ___________ Date: ______________ Checked by Payroll: _______________
