Serving: Hildago,Starr,Willacy Counties,Brooks,Cameron,Duval,Jim Hogg,Jim Wells,Kenedy,Kleberg,Zapata
EMPLOYMENT FORM
SSN:
Employee Name:
Date Of Birth:
Date Employe:
Position:
Department:
Employment Start Date:
 Supervisor:
Married
Single
 Married but withhold at higher single rate
Filing Status:
Allowances Claimed:
Pay Rate:
Part Time
Employee Type:
 Temporary
Regular/Probationary
Wage Classification:
 Hourly
Salary
 Per Visit
 Contract
Comments:
Mailing Address:
Cell Phone Contact:
Other Phone Contact:
Email Address:
Date:
Employee Signature:
Department of Head Signature:
Date:
Administrator's Approval
 Date:
Thank you for your interest in becoming a Criterion HealthCare,Inc team member. The information you
Submit below will allow us to contact you at a convenient time and will be kept for future reference.
We do not discriminate on the basis of race,religion,color,creed,gender,sex,age,national
origin,marital, disability or veteran status or any other legally. WE ARE AN EQUAL OPPORTUNITY
EMPLOYER