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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 ! Ves <br />Date Employee Started Work: <br />Average Number of Hours Worked Per Week: <br />Rate of Pay or Salary: $ <br />Hourly ! Monthly ! nnnually ! <br />Pay Frequency: <br />Daily f Weekly ! rvery Two Weeks ! rwo Times a Month f] Monthly ! <br />Tips: E wo <br />Commissions: f No <br />Bonuses: I ttlo <br />Overtime: I wo f <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? f, 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; 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 />DVRSch oo lToWo rk @ d sh s.wa. sov Page 22