EMPLOYEE PAYROLL INFORMATION

Please Print in Block Letters (and attach Void cheque)

Company Name: _________________________________________

Employee Number (if required) ___________ Start Date: day _____ mo. _______ year _____

Surname: _________ __________________First Name: ___ _____Initial: _____

Address: _______________ __________________________________

City: ______BRAMPTON________ Province: ____ON_____ Postal Code: _____ ____

Phone Number: _______ E-mail address ____ _________

Social Insurance Number: _____________________ Date of Birth: day __mo ___ year __

BANK Name: _____ ____Transit# (5 digits)___ ______

Account #: __________________________________________________________

Password to Access E-mail Pay Statement: (4-10 alphanumeric) _____ __________

Salary _____ Hourly ______

Salary Rate (if applicable) ___________________ Hours per week ________________________

Hourly Rate (if applicable) __________________

TD1 Federal Claim amount: ________________ TD1 Provincial Claim amount: _______________

Extra Taxes Requested: ___________________

Job Title: ___________

Department: ___________________________________________________________________

Supervisor: __________ _____________________________________

Employee Signature: ____________________________________Date: ____ ______