Date/Fecha
/
Month
/
Day
Year
Date
Last /Apellido:
Social Sec. Num:
First/Primer:
Address/Domicilio
DOB/Fecha de Nacimiento:
Emergency Contact Name and Phone Number/Contacto de Emergencia Nombre y Numero De Telefono:
Phone/Telefono:
Company/Compania:
Position/Posicion:
Dates Employed/Fechas Trabajadas:
/
Month
/
Day
Year
Date
Month/Mes
Supervisor:
Duties responsible for/Deberes responsable:
Address/Domicilio:
Reason for leaving/Razon por irse:
Year/Ano
to/a
-0-16
Microsoft Excel
Microsoft Excel
Microsoft Word
Certified
Collator
UPS Shipping
UPS Shipping
Stand Up
Packing
FedEx Shipping
Order/Cherry Picker
Production line
Reach Truck
Quality Control
Electric Pallet Jack
Inspection
Manual Pallet Jack
Bendi
Carpenter
Carpenter
Electrician
Cycle Count
HVAC
Inventory
Painting
Order Puller
Plumbing
Picking
Lift 10 20lbs
Lift 10 20lbs
Lift 20 40lbs
Lift 50 lbs
Can't lift
Use of Hand tools
Label/Ticketing
Label/Ticketing
Shipping
Shipping
Receiving
Assembly
Stocking
Blueprints
Palletize
Load/Unload
RF Scanner
Calipers
Calipers
Bob Tail
Circuit Boards
Bridge Port
Clean Room
CNC Operator
Color Codes
CNC Programmer
CNC Set up
Crimpers
Deburring
Line Lead
Micrometers
Drill Press
Shift Lead
Microscope
Machinist
Supervisor
Schematics
Engine Lathe
Manager
Soldering
Mill
Surface Mount soldering
Surface Mount soldering
Wire Bonding
Wiring Diagrams
Porters
Porters
Facility Maintenance
Hotels
Electrical
Residence Cleaning
Janitorial
Office Cleaning
Pharmaceutical
Housekeeping
Cook
Cook
Dishwasher
Food Manufacturing
Housemen
Prep Cook
Front Desk
GMP knowledge
Packaging
MIG
Food handler
TIG
TIG
Maintenance Mechanic
Date
/
Month
/
Day
Year
Date
(a) First name and middle initial/ Primer Nombre
Last name/Apellido
(b) Social security number/ Seguro Social
Address/Domicilio
City or town, state, and ZIP code/ Cuidad, Estado, Codigo Postal
Single or Married filing separately
Single or Married filing separately
Married filing jointly (or Qualifying widow(er))
Head of household (Check only if you're unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying
(c) If there are only two jobs total, you may check this box. Do the same on Form W 4 for the other job. This option is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld
(c) If there are only two jobs total, you may check this box. Do the same on Form W 4 for the other job. This option is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld
Multiply the number of qualifying children under age 17 by $2,000/ Multiplique numero de dependes menores de 17 anos por $2,000
Multiply the number of other dependents by $500/ Multiplique numero de otros dependes por $500
Add the amounts above and enter the total here 3/ Sume los totales de arriba y ponga el total de la cantidad aqui
(a) Other income (not from jobs). If you want tax withheld for other income you expect this year that won't have withholding, enter the amount of other income here. This may include interest, dividends, and retirement income 4(a)
(b) Deductions. If you expect to claim deductions other than the standard deduction and want to reduce your withholding, use the Deductions Worksheet on page 3 and enter the result here 4(b)
(c) Extra withholding. Enter any additional tax you want withheld each pay period
Employee's signature (This form is not valid unless you sign it.)/ Firma
Date/Fecha
/
Month
/
Day
Year
Date
Last Name/ Apellido
First Name/Primer Nombre
Middle Initial
Address/Domicilio
Apt. Number/Numero de Apt.
City/Cuidad
State/Estado
Zip Code/ Codigo Postal
Date of Birth (mm/dd/yyyy)/ Fecha De Nacimiento
/
Month
/
Day
Year
Date
U.S. Social Security Number/Numero de Seguro Social
Employee's E mail Address/ Correo Electronico
example@example.com
Employee's Telephone Number/Numero de Telefono
1. A citizen of the United States
1. A citizen of the United States
2. A noncitizen national of the United States (See instructions)
3. A lawful permanent resident (Alien Registration Number/USCIS Number):
An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy):
/
Month
/
Day
Year
Date
1. Alien Registration Number/USCIS Number:
2. Form I 94 Admission Number:
Foreign Passport Number:
Country of Issuance:
Signature of Employee/Firma
Today's Date (mm/dd/yyyy)/ Fecha de hoy
/
Month
/
Day
Year
Date
Signature of Preparer or Translator
Expires
First Name (Given Name)
M.I.
Citizenship/Immigration Status
Issuing Authority
Expiration Date (if any) (mm/dd/yyyy)
/
Month
/
Day
Year
Date
Additional Information
The employee's first day of employment (mm/dd/yyyy):
Today's Date (mm/dd/yyyy)
/
Month
/
Day
Year
Date
Title of Employer or Authorized Representative
Name
First Name of Employer or Authorized Representative
Last Name of Employer or Authorized Representative
Employer's Business or Organization Name
Employer's Business or Organization Address (Street Number and Name)
City or Town
State
ZIP Code
Last Name (Family Name)
Middle Initial
Date (mm/dd/yyyy)
/
Month
/
Day
Year
Date
Document Title
Document Number
Signature of Employer or Authorized Representative
Name of Employer or Authorized Representative
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