Welcome to New Hire Documents!
Application ID #:
When printing or saving, ignore other states withholding forms.
Job Class Code:
Regular Pay Day:
Does a written agreement exist providing the rate(s) of pay?
If yes, are all rate(s) of pay and bases thereof contained in that written agreement?
Legal Name of Hiring Employer :
Other Names Employer is doing business as (if applicable):
Current WC policy number::
Address of Main Office:
Employer’s Mailing Address (if different than above):
Employer’s Telephone Number:
Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.
List A: Documents that Establish Both Identity and Employment Authorization
List B: Documents that Establish Identity
List C: Documents that Establish Employment Authorization
Paid Sick Leave
The following applies to the employee identified on this notice::
Accrues paid sick leave only pursuant to the minimum requirements stated in Labor Code §245 et seq. with no other employer policy providing additional or different terms for accrual and use of paid sick leave.
Accrues paid sick leave pursuant to the employer’s policy which satisfies or exceeds the accrual, carryover, and use requirements of Labor Code §246.
Employer provides no less than 24 hours (or 3 days) of paid sick leave at the beginning of each 12-month period.
The employee is exempt from paid sick leave protection by Labor Code §245.5. (State exemption and specific subsection for exemption):
Paid sick leave policy effective date to be discussed at new hire orientation.
Company has PSL plan complaint with state mandated plan. See handbook for details.
First Name of Company Representative:
Last Name of Company Representative:
Title of Company Representative: