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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 I ves <br />Date Employee Started Work: <br />Average Number of Hours Worked Per Week: <br />Rate of Pay or Salary: $ <br />Hourly I Monthly I Annuallv f] <br />Pay Frequency: <br />Daily I Weekly I rvery Two Weeks ! rwo Times a Month ! vonthly ! <br />Yes; if yes, how often and how much? <br />Yes; if yes, how often and how much? <br />Yes; if yes, how often and how much? <br />Yes; if yes, how often and how much? <br />Work Schedule (include exact times when possible): <br />Monday Tuesday Wednesday Thursday Friday Saturday Sunday <br />ls health insurance available: f] wo ! ves <br />t. lf yes, did the employee enroll in the health plan? <br />a. lf yes, when does the coverage begin? <br />No fves <br />b. lf yes, what is the employee's portion of the premiums? $ <br />Name and Title of Person Who Completed This Page: Date: <br />Tips: <br />Commissions <br />Bonuses: <br />Overtime: <br />No <br />No <br />No <br />No <br />DVRSchoolToWo rk@dshs.wa.sov Page 22