Client Co. ______
Hire Date______
C&S SERVICES
1016 Triplett Blvd, Akron OH 44306
Instructions to Applicant: C&S Services has been contracted by your worksite employer to provide payroll and general administration services. C&S acts as your administrative or W-2 employer, taking care of employee-related paperwork, maintaining and producing payroll, etc. Please print legibly and complete the “Employee Information” sections on this form, a W-4 Employee Withholding Allowance Certificate, and a State Employee’s Withholding Certificate. C&S Services is an equal opportunity employer and does not discriminate on the basis of race, religion, color, sex, age, national origin, disability or any other characteristics or condition protected by federal, state or local law. The use of C&S Services includes C&S Services, Inc., C&S Services North LLC, C&S Services East LLC, C&S Services West LLC, C&S Services A LLC, C&S Services B LLC, C&S Services C LLC.
Please answer all questions. If the answer to any question is “no” or “None,” do not leave the item blank, but write “No” or “None.” This is important!
The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age.
Date: ______
Name: ______
(First)(Middle)(Last)
Address: ______
(Street) (City)(St)(ZIP)
County of Residence: ______Emergency Contact: ______
Phone Number (______)______Emergency Phone (______)______
Date of Birth ______Social Security number ______
Are you subject to child support and wage withholding (circle response)?YESNO
If yes, please provide a copy of any active child support wage withholding order to C&S Services with this paperwork.
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Employee Information—Voluntary: C&S Services, Inc. is an equal opportunity employer and does not discriminate based on race, religion, national origin, gender, veteran status or disability status in which the person is able to perform the essential functions of the position. Please check one for each category below (optional):
1. Race / White / Black / 2. Sex / Male / Female Hispanic / Asian / 3. Veteran / Yes / No
Native Am / 4. Disabled / Yes / No
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This certifies that this application was completed by me and that all entries on it and information in it are true to the best of my knowledge.
Employee’s Signature______Date______
FOR CLIENT OFFICE USE ONLY:
Client Name:______
Hire Date:______
Rate of Pay:______
Job Title:______
Pay Cycle (circle one): Weekly Bi-Weekly Semi-Monthly Monthly
Employee is (circle applicable):
Full-Time Part Time
Hourly Commission Overtime Exempt
Client Authorization Signature:______Date:______
Remarks:
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