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Congratulations! You are Employed ! <br />NOW What? please work with your job coach to complete the form below. <br />Employee's Name Employer's Name <br />Employee's Job Title Employer's Address: <br />ls this a new job? ! No <br />Date Employee Started Work: <br />Average Number of Hours Worked Per Week: <br />Rate of Pay or Salary: $ <br />Hourly f Monthly I Rnnualty I <br />Pay Frequency: <br />Daily fl Weekly ! every Two Weeks ! rwo Times a Month f] ruonthlv ! <br />Tips: tr frf o ! Ves; if yes, how often and how much? <br />Commissions: ! ruo I Ves; if yes, how often and how much? <br />No f]ves; if yes, how often and how much? <br />No n ves; if yes, how often and how much? <br />Work Schedule (include exact times when possible): <br />Monday Tuesday Wednesday Thursday Friday Saturday <br />Yes <br />Bonuses: <br />Overtime <br />ls health insurance available: I ftf o ! Ves <br />t. lf yes, did the employee enroll in the health plan? f] ruo f]ves <br />a. lf yes, when does the coverage begin? <br />b. lf yes, what is the employee's portion of the premiums? S <br />Name and Title of Person Who Completed This Page: Date: <br />Sunday <br />DV RSc h oo lToWork (d d shs.wa .eov Page22