Post Employment Information Form

PLEASE PRINT ALL INFORMATION REQUESTED EXCEPT SIGNATURE

POST EMPLOYMENT INFORMATION FORM

TO BE COMPLETED AFTER EMPLOYEE HAS BEEN HIRED

Height ______ ft. ______ in. Weight __________ Birth date _______________

Married ___ Yes ____ No If married, how long? _____  Single ___Separated ____Divorced ____Widowed

Full name of spouse ______________________________ Occupation ____________________________________

Name of company ________________________________ Telephone (     )

PERSON TO BE NOTIFIED IN CASE OF EMERGENCY

Name _________________________________________ Telephone (        )

Address ________________________________________ Relationship ___________________________________

FOR INSURANCE PURPOSES ONLY: LIST ALL DEPENDENTS

NAME

RELATIONSHIP

BIRTH DATE

SSN

TO BE COMPLETED

BY EMPLOYER

Date of employment ________________ Job title ___________________ Dept. ___________________________

Location___________________________ Rate of pay ________ ___Full-time ___Part-time ____ Salaried

Applicant s signature acknowledging above information __________________________________________________

Drug test confirmation number _____________________________

Name of person verifying information _________________________________________________________________

Name of person authorizing employment _____________________________________________________________