Dental Health Services Portal

Payroll Information Form for New Hire

First Name *

Last Name *

Phone Number *

Email *

New Hire Date

Rehire Date

Personal Information

Employee Name *

Street Address *

City

State *

Zip Code *

Date of Birth *

Sex *

Cell Phone Number *

Personal email *

Work email *

Employment Information

Salary *

Availability *

Full Time

Part Time

Sub

W4 *

Allowances *

FSLA Status *

Time Off Benefits *

Sick Time

PTO

TB Clearance Date *

TB Expiration Date *

Covid Vaccination Dates

1st Dose *

2nd Dose *

Livescan Reimbursement Date *

Livescan Completion Date *

Referred By

Referral Bonus (Date Paid)

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