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Get UT DWS-ESD 630 2014

DWS-ESD 630 State of Utah Department of Workforce Services EMPLOYMENT INFORMATION Rev. 03/14 Case Name Employed Person Case SSN For new and returning employment the entire form must be completed and signed. To verify changes to your current employment the employer information and questions relating to changes of employment must be completed and the form signed. Please use a black pen to complete form. Employer Information Company Name Company Address Name of Supervisor or HR contact Corporate Name if different Phone Number Date employment began or returned to work after leave of absence Is the employment temporary Yes No If yes what is the expected end date Hourly wage or Salary /hr. If terminated list the termination date Date of final pay check Employer Signature Date Customer Signature Additional verification will be required if employer does not sign form. Return form to employee or to DWS. If returning to DWS mail email or fax to Salt Lake City Area 801-526-9500 Imaging Operations Toll free 1-877-313-4717 P. Salary /Monthly Yearly Number of hours worked each week Check scheduled work days Mon Tues Wed Thurs Fri Sat Sun Enter work schedule ex 9 a*m*to 6 p*m* From a*m* / p*m* To a*m* / p*m* 6. Is overtime offered on a regular basis No Weekly overtime hours Overtime rate 7. Will the weekly number of hours worked each week vary If yes Minimum hours Maximum hours th 8. How often paid Weekly Every Two Weeks ex every other Friday Twice a Month ex 5 and 20 Other explain If paid weekly or every two weeks list day of the week ex Fridays If paid twice a month list dates 9. Date first paycheck will be or was received What will be the estimated gross amount before taxes Hours paid on the first check 10. When does the pay period end ex every other Friday or 15 30 11. Does employment include Tips Commission Health Savings Account or Shift Differential If yes list amount and frequency 14. O Box 143245 Salt Lake City UT 84114-3245 Email imagingops utah. gov Equal Opportunity Employer Program Auxiliary aids and services are available upon request to individuals with disabilities by calling 801 526-9240. Individuals with speech and/or hearing impairments may call Relay Utah by dialing 711. Spanish Relay Utah 1-888-346-3162. Salary /Monthly Yearly Number of hours worked each week Check scheduled work days Mon Tues Wed Thurs Fri Sat Sun Enter work schedule ex 9 a*m*to 6 p*m* From a*m* / p*m* To a*m* / p*m* 6. Is overtime offered on a regular basis No Weekly overtime hours Overtime rate 7. Will the weekly number of hours worked each week vary If yes Minimum hours Maximum hours th 8. Is overtime offered on a regular basis No Weekly overtime hours Overtime rate 7. Will the weekly number of hours worked each week vary If yes Minimum hours Maximum hours th 8. How often paid Weekly Every Two Weeks ex every other Friday Twice a Month ex 5 and 20 Other explain If paid weekly or every two weeks list day of the week ex Fridays If paid twice a month list dates 9. How often paid Weekly Every Two Weeks ex every other Friday Twice a Month ex 5 and 20 Other explain If paid weekly or every two weeks list day of the week ex Fridays If paid twice a month list dates 9. Date first paycheck will be or was received What will be the estimated gross amount before taxes Hours paid on the first check 10. .

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