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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? f, No <br />Date Employee Started Work <br />Average Number of Hours Worked Per Week: <br />Rate of Pay or Salary: $ <br />Hourly ! Monthly f, nnnually I <br />Pay Frequency: <br />Daily ! Weekly ! every Two Weeks f rwo Times a Month ! vonthly f] <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: I ruo ! ves <br />L. lf yes, did the employee enroll in the health plan? I ruo ! ves <br />a. lf yes, when does the coverage begin? <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 />Yes <br />Tips: <br />Commissions: <br />Bonuses: <br />Overtime: <br />No <br />No <br />No <br />No <br />DVRSchoolToWo rk@dshs.wa.pov Page22