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Date/Fecha

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:

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

Certified

Collator

UPS Shipping

Carpenter

Lift 10 20lbs

Use of Hand tools

Label/Ticketing

Shipping

Calipers

Surface Mount soldering

Porters

Cook

Food handler

TIG

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

(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

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

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

An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy):

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

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)

Date

Additional Information

The employee's first day of employment (mm/dd/yyyy):

Today's Date (mm/dd/yyyy)

Date

Title of Employer or Authorized Representative

Name

First Name of Employer or Authorized RepresentativeLast 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)

Date

Document Title

Document Number

Signature of Employer or Authorized Representative

Name of Employer or Authorized Representative