EMPLOYEE INFORMATION
NAME:
PREFERRED NAME:
(As it appears on Social Security card)
ADDRESS:
ST:
CITY:
COUNTY:
ZIP:
PERSONAL EMAIL ADDRESS:
HOME PHONE #:
WORK PHONE #:
CELL #:
WORK FAX #:
SOCIAL SECURITY #:
BIRTHDATE:
DRIVERS LICENSE #:
STATE:
MARITAL STATUS:
MARRIED
EXT:
EXPIRES:
SINGLE
ETHNIC ORIGIN (For EEO filing purposes only):
White
Black or African American
Native Hawaiian or Pacific Islander
Asian
Hispanic or Latino
American Indian or Alaskan Native
PRIMARY EMERGENCY CONTACT:
HOME PH #:
Two or More Races
RELATIONSHIP:
WORK PH #:
CELL PH #:
ADDRESS:
CITY:
STATE:
SECONDARY EMERGENCY CONTACT:
HOME PH #:
ZIP:
RELATIONSHIP:
WORK PH #:
CELL PH #:
ADDRESS:
CITY:
STATE:
ZIP:
FOR CLIENT SERVICES DATABASE: (Please complete if relevant to advertising).
PREVIOUS EMPLOYER(S)
CLIENTS
TYPE OF INDUSTRY (CLIENT)
DIRECT DEPOSIT AUTHORIZATION
COMPANY:
Moroch
Inspire
NEXTMedia
O&E
Side Chops
LimeGreen
To enroll in Direct Deposit, simply fill out this form and give to your payroll manager. Attach a voided check for each checking account - not a deposit
slip. If depositing to a savings account, ask your bank to give you the Routing/Transit Number for your account. It isn’t always the same as the number
on a savings deposit slip. This will help ensure that you are paid correctly.
Below is a sample check MICR line, detailing where the information necessary to complete this form can be found.
IMPORTANT! Please read and sign before completing and submitting.
I hereby authorize Moroch Holdings, Inc. to deposit any amounts owed me, as instructed by my employer, by initiating credit entries to my account at
the financial institution (hereinafter “Bank”) indicated on this form. Further, I authorize Bank to accept and to credit any credit entries indicated by
Moroch Holdings, Inc. to my account. In the event that Moroch Holdings, Inc. deposits funds erroneously into my account, I authorize Moroch Holdings,
Inc. to debit my account for an amount not to exceed the original amount of the erroneous credit.
This authorization is to remain in full force and effect until Moroch Holdings, Inc. and Bank have received written notice from me of its termination in
such time and in such manner as to afford Moroch Holdings, Inc. and Bank reasonable opportunity to act on it.
Employee Name:
SS#:
Signature: ______________________________________________
Date:
ACCOUNT INFORMATION
The last item must be for the remaining amount owed to you. To distribute to more accounts, please complete another form.
Make sure to indicate what kind of account, along with amount to be deposited, if less than your total net paycheck.
1. Bank Name:
City/State:
Routing Transit #:
Checking
Account #:
Savings
2. Bank Name:
Entire Net Amount
or
Entire Net Amount
or
Entire Net Amount
Account #:
Savings
3. Bank Name:
I wish to deposit: $
City/State:
Routing Transit #:
Checking
or
City/State:
Routing Transit #:
Checking
I wish to deposit: $
Account #:
Savings
I wish to deposit: $
CONSENT TO PAYROLL DEDUCTIONS
Your execution of this form evidences your consent to deductions from your wages – please read carefully.
I hereby authorize Moroch Holdings, Inc. and its interrelated “family of companies” (hereafter referred to as MHI), to deduct
from any sums due to me (including my wages &/or expense reports) for the following items (to the extent allowed by law):







Medical &/or Life Insurance Premiums
Payroll advances (including, but not limited to; advances of vacation time, overpayment of wages, advances of
wages, advances for business expenses)
All charges for items purchased by myself from MHI
Returned checks signed by myself
Amounts paid by MHI on my behalf
Property (e.g. computer equipment, training manuals, entry cards, office keys, etc.) issued to me by MHI that is
damaged or not returned
Outstanding balance on corporate credit card(s) or travel accounts
I hereby acknowledge that if my employment with MHI is terminated, by myself, or MHI, any sums due to MHI and/or any
outstanding balance due on corporate credit card(s) or travel accounts may be deducted from my final paycheck.
I will be responsible for providing all information necessary to clear any open balances in my Clearing Account, and providing
documentation of a zero balance on any corporate credit card(s) or travel accounts, including (but not limited to) the following:
Travel expenses, including (but not limited to) airline tickets; hotel; motel; mileage; meals; taxis; limo; car rentals; tips;
tolls; and other incidental charges.
In addition, payment arrangements must be made prior to termination for any personal charges incurred, such as (but not
limited to) the following:
Postage, shipping, overnight delivery, long distance phone charges, and personal items charged to corporate
accounts, including corporate credit card(s) and travel accounts.
All Petty Cash receipts must be turned in and payment of any cash advance, payroll advance or reimbursement of relocation
advance must be made prior to termination.
It is understood that no deduction from my wages will reduce my wages below applicable minimum wage for the period,
pursuant to any federal, state of local law.
This form does not create any contract for employment or any benefit. I may terminate my employment at any time without
cause and MHI retains the same right.
Authorized by:
_____________________________________________________________
EMPLOYEE’S NAME (Typed or Printed)
this _____________ day of , 20________
_____________________________________________________________
EMPLOYEE’S SIGNATURE
_________________________________
SOCIAL SECURITY NUMBER