First Name:     

Last Name:     

CWID:  

Job Title:   

Department:    

Box Number:   

Date of Hire:   

Status:    Full-time Part-time

Type:    Bi-weekly Salaried Temporary

Eligible for Benefits:    Yes No

Supervisor e-mail address:   

Work phone number:   

E-mail address to send confirmation:   

Enter your comments/questions in the space provided below:

If you are completing this form for another employee, please give us your name and email and we will confirm registration to you also. Thank You!

Name:

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