1.

Employee Information Form

PREFERRED NAME:

First

Name(Required)

First Middle Last

Address(Required)

Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

Phone(Required)

Social Security(Required)

Gender

Male

Female

Other

(FOR TAX FILING PURPOSES)

MARITAL STATUS :(Required)

SINGLE:

MARRIED: (Filing Separately):

MARRIED: (Filing Jointly):

# OF DEPENDENTS:(Required)

Additional Earnings or Deductions (401k, med-125, garnishments, etc.)

BIRTH DATE:(Required)

MM slash DD slash YYYY

HIRE DATE:

MM slash DD slash YYYY

EMAIL ADDRESS:(Required)

HOURLY RATE: $

(Per The Bin Store)

OR SALARY: $

DIRECT DEPOSIT INFO

Check ONE:(Required)

CHECKING

SAVINGS

BANK NAME:(Required)

ROUTING(Required)

ACCOUNT(Required)

I verify all this infomation is accurate Signature(Required)

Please Upload Photo ID(Required)

Drop files here or Select files

Max. file size: 256 MB, Max. files: 2.

Driver’s License etc

Phone

This field is for validation purposes and should be left unchanged.