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Provider Wage Supplement Staff Change
Logan Crouch
2021-11-16T17:11:08-06:00
Tarrant TRS Supplement Wage Program - Staff Change
Step 1 of 4
25%
PRIM ID
Basic Information
Provider Name
*
License Number
*
Your Name
*
First
Last
Your Title
*
Your E-mail
*
Enter Email
Confirm Email
Your Phone Number
*
Employee's Information
Employee's Name
*
First
Last
Employee's Title
*
Employee's Date of Birth
*
Employee's Last 4 digits of SSN
*
Employee's Hire Date
*
Employee ID
(If employee has one)
Employee's Home Address
*
Street Address
City
ZIP / Postal Code
Change Information
Employee Change Type
*
New Hire
Position change
Rate of Pay
Extended Leave
Resignation
Termination
Other
Employee's New Title
Employee's Average Hours Worked Each Week
*
Employee's Hourly Pay/Salary
*
Estimated number of days needed for leave
Employee's End Date
*
Additional Change Notes
Review Information
Summary
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06/02/2023
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By signing this document, you agree to the following statement:
*
I certify that all information provided on this form is true and accurate. I understand that giving false information may constitute fraud and could result in prosecution.
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