Employee Information Sheet

TOWN OF BURGAW EMPLOYEE INFORMATION SHEET
Employee Information
Full Name*

First NameMiddle NameLast Name
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Physical Address (if different from mailing address)

Street Address

Street Address Line 2

CityState

Zip Code
Email (pay stub will be emailed to this address)*
example@example.com
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Marital Status*
Sex*
US Citizen*
Additional Information Needed for Background Check
Other Names/Alias
Social Security Number*
Driver's License Number*
Driver's License State*

Street Address

Street Address Line 2

CityState

Zip Code
Notify in Case of Emergency
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
If able, please upload a picture of the front and back of your driver's license as well as a picture of your social security card. If unable, please submit as soon as possible to Kimberly Rivenbark, HR Director, as to not hold up your background check.

Cancelof
Should be Empty:

Employee Information