AFFILIATED PHYSICIANS

www.affiliatedphysicians.net

18 East 48th Street, 2nd Floor, New York, NY 10017 Tel (212) 935-8725 Fax (212) 935-8854
Personnel Action Form
Company: ___Executive

Medeast___

Location: ___Midtown

(Circle One)

Pelham___

(Circle One)

Primary hours in the following counties?

Yes

No

Employee Information:

New York, Bronx, Queens, Richmond, Kings, Dutchess, Nassau, Orange, Putnam, Rockland, Suffolk and Westchester

Name: _________________________________________________________________________
Last
First
Middle
Address: _______________________________________________________________________
City: ____________________________ State: __________

Zip Code: ___________________

Social Security #: ______________________________ Phone #: ____________________________

D.O.B: _______________ Email: _____________________________________________________

Signatures:

Pay:

Type of Action:

Emergency Contact Name: ______________________________ Phone #: __________________

Position: __________________________
Hire

Terminate Voluntary

Salaried employee OR

Department: __________________________

Terminate Involuntary

Hourly employee

AND

Pay Raise
Full Time

Change of Address
OR

Part Time

Other: ___________________________________________________________________________

Starting Salary or Hrly Rate: $________________

New Salary or Hrly Rate:

$________________

Complete NYS form LS52 and give employee a duplicate signed copy!

Effective Date of above action: ____________________

Employees Signature: ____________________________________ Date: ________________
Managers Signature: _____________________________________ Date: ________________

Labor Law Section 195(1)

Notice and Acknowledgement of Wage Rate and Designated Payday
Hourly Rate Plus Overtime
Employer
Company Name _Executive Medical Services, pc_____

Employee
Name ______________________________________

FEIN _22 3712962________

Street address _______________________________

Street address: _15 Canal Rd.____

Apt. _________City __________________________

City _Pelham Manor___State ___NY_______

Zip _10803_________________________

State __________________Zip:_________________
Phone (_______) ________ - ___________________

Phone (914)718- 1144____________

Preparers Name _____________________________
Preparers Title ______________________________

Your rate of pay:___________________________________________________________________per hour.

Your overtime rate of pay: __________________________________________________________ per hour.
Designated pay day: _Friday____________________and every other Friday thereafter.___________________
I hereby certify that I have read the above and the information contained in this form is true and accurate to the
best of my knowledge and belief. Any false statements knowingly made are punishable as a class A
misdemeanor (Section 210.45 of the New York State Penal Law).

Date: ______________________________

__________________________________________
[Preparers Signature]

General Statement Regarding Overtime Pay in New York:

Almost all employees in New York must be paid overtime wages of 1 times their regular rate of pay for all
hours worked over 40 per workweek. A very limited number of specific categories of employees are covered
by overtime at a lower overtime rate or not at all.
I hereby acknowledge that I have been notified of my wage rate, overtime rate, and designated pay day on the
date set forth below.
Date: ______________________________

__________________________________________
[Employees Signature]

A duplicate signed copy of this form is to be provided to the employee. Original must be kept by the employer.

LS 52 (10/09)