Employee Processing Request

EMPLOYEE PROCESSING REQUEST

Request Information

Requestor Name:    Department:

Request Date:    Contact Phone:    Contact Email:

Action Requested (select all that apply)

New Hire Rehire Status Change (FT/PT) Termination

Payroll Setup / Update Benefits Enrollment Background Check IT Access / Accounts

Equipment Request (laptop, phone) Other:

Employee Personal Information

Phone:    Email:    SSN (last 4):

Position and Compensation

Department:    Manager:

Proposed Start Date:    Employment Type:    FTE:

Base Salary/Rate:    Pay Frequency:    Eligible for Overtime: Yes

Payroll, Benefits & Tax

Benefits Eligible: Yes No    Retirement Plan Enrollment:

Work Location, Equipment & IT Access

Primary Work Location:    Office/Cost Center:

Employment History (most recent first)

Title:    Dates Employed:

Title:    Dates Employed:

Education

Graduation Date:    Major/Field:

References (Professional)

Phone:    Email:    Relationship:

Phone:    Email:    Relationship:

Phone:    Email:    Relationship:

Legal Disclosures, Authorization & Certification

At-Will Employment: I understand and acknowledge that, unless otherwise provided in a written agreement signed by an authorized representative of the employer, employment is at-will. Either the employee or the employer may terminate the employment relationship at any time, for any lawful reason, with or without cause or notice. This form does not alter or modify at-will employment except by express written instrument.

Equal Employment Opportunity: The employer provides equal employment opportunity to all applicants and employees without regard to race, color, religion, sex, national origin, age, disability, genetic information, veteran status, or any other characteristic protected by applicable law. Employment decisions are based on legitimate business needs, job-related qualifications, and individual merit.

Background Checks & References Authorization: I certify that the information contained in this Employee Processing Request is true and complete to the best of my knowledge. I authorize the employer, its agents, and designated third parties to contact previous employers, educational institutions, licensing authorities, and listed references to verify information provided herein and to conduct background, criminal history, and other pre-employment checks as permitted by law. I release those parties from all liability for providing such information.

Resume Government ID / Proof of Eligibility Signed Offer Letter (if applicable)

Processing Checklist (for HR use)

HR Approver Name:    HR Approver Title:

HR Approval Date:    HR Notes:

Acknowledgement & Signature

By signing below, I acknowledge the foregoing statements, authorize processing of this request, and consent to the background and reference checks described above. I understand that this request initiates administrative actions necessary for employment and that some actions may be conditional upon successful completion of background checks and receipt of required documentation.

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