Villanova University New Employee Personal Information Form

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Phoebe Jordan
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Villanova University New Employee Personal Infmation Fm Employee Name (as it appears on your social security card): Department: of Birth: Gender: US Citizen?

1 Villanova University New Employee Personal Infmation Fm Employee Name (as it appears on your social security card): Department: of Birth: Gender: US Citizen? If no, Visa status/permanent resident #: of Hire: Social Security Number: Marital Status: Veteran s Status: What is your ethnicity: Hispanic Latino? Not Hispanic Latino Please select one me races that describe how you consider yourself: American Indian Alaska Native Asian Black African American Native Hawaiian Other Pacific Islander White Address and Phone Infmation: Street Address: City, State Zip: Home telephone #: Cell Phone #: Emergency Contact Infmation: Contact #1 Name: Address, City, State, Zip: Relationship: Phone #1: Phone #2: Contact #2 Name: Relationship: Address, City, State, Zip: Phone #1: Phone #2: Dependent infmation (required f tuition benefits, even if not electing health benefits) Full Name (First, Middle, Last) Social Security Number of Birth (MM/DD/YYYY) Gender (M F) Relationship (Spouse/Child) Signature

WORKERS COMPENSATION EMPLOYEE NOTIFICATION I understand that the University is required to pay f all my reasonable and necessary medical services required as a result of a wk-related injury.

2 WORKERS COMPENSATION EMPLOYEE NOTIFICATION I understand that the University is required to pay f all my reasonable and necessary medical services required as a result of a wk-related injury. If I am involved in a wk-related injury, I am to infm my department head supervis without delay. I understand that I am required to treat with a health care provider identified as a panel physician and a facility on the list posted by the University on employee bulletin boards, and on the Human Resources website. I further understand that this restriction does not apply to emergency treatment if I am faced with an immediate life-threatening medical emergency. Furtherme, I understand that I am required to treat with a panel physician f the 90 day period from the date of first treatment, and that should I not do so, the University is then not responsible f paying f health care services that I receive from other sources during the initial 90 day period. During that 90 day period of treatment by the panel physician, should the panel physician recommend invasive surgery, I am entitled to seek a second opinion from a physician of my choice at the University expense. Should my physician s opinion differ from that of the panel physician, and I choose to follow my physician s opinion, the panel physician will treat me accdingly during the mandaty 90 day period. I understand that I may seek treatment from a health care provider of my own choice after I have treated with a panel physician f the mandaty 90 day period. If I choose to do this, I understand that I must infm the Human Resources offices within 5 days of my first visit. If I do not infm the Human Resources office of my election to seek treatment from a health care provider of my choice within the 5 days following the first visit after the mandaty 90 day period of treatment by the panel physician, I understand the University is not responsible f payment f any services perfmed dered by this health care provider until I do infm the Human Resources office of my change to my own health care provider. I understand that, once I properly infm the Human Resources office that I am treating with a health care provider following my treatment by a panel physician, all reasonable and necessary health care services will be paid by the University if it is determined that they continue to be needed f treatment of a bona fide wk-related injury. I am further infmed that the health insurance plans offered by the University f non-wk-related medical needs will not pay f treatment which is a result of a wk-related medical condition, either befe, during, after the 90 day time frame. I acknowledge that I have been infmed of these rights and duties and that I understand them. Employee Name (please print) Employee Banner ID# Employee Signature Revised 01/13

3 WORKERS COMPENSATION INFORMATION The wkers compensation law provides wage loss and medical benefits to employees who cannot wk, who need medical care, because of a wk-related injury. Benefits are required to be paid by your employer through insurance provided by the University. The University is required to post the name of the company responsible f paying wkers compensation benefits at its primary place of business and at its sites of employment in a prominent and easily accessible place, including, without limitation, areas used f the treatment of injured employees f the administration of first aid. You should rept immediately any injury wk-related illness to your supervis. Your benefits could be delayed denied if you do not notify your supervis immediately. If your claim is denied by the University, you have the right to request a hearing befe a wkers compensation judge. The Bureau of Wkers Compensation cannot provide legal advice. However, you may contact the Bureau of Wkers Compensation f additional general infmation at: Bureau of Wkers Compensation, 1171 South Cameron Street, Room 103, Harrisburg, Pennsylvania ; telephone number within Pennsylvania (800) ; telephone number outside of the Commonwealth (717) ; TTY (800) (f hearing and speech impaired only); PA Keywd: wkers comp. I hereby acknowledge receipt of the WORKERS COMPENSATION INFORMATION fm. Employee Name (please print) Employee Villanova ID# Employee Signature Revised 01/13

4 Villanova University Payroll Department Direct Deposit Request Check all that apply: New Direct Deposit Additional Direct Deposit Change of account number(s) Change of dollar amount(s) Cancel Direct Deposit: Bank Name: Account #: If canceling current direct deposit please check one below: Keep existing deposit active until new request is active. (Usually one full pay cycle) Terminate current direct deposit, listed above, immediately. (You will receive a check until new deposit is active) Note: If above is left blank, current direct deposit will be terminated. I hereby authize Villanova University to initiate credit entries to the account and financial institution listed below and to charge the same said account only to reverse any credit posted erroneously. This authization is to remain in full fce and effect until Villanova University has written notification from me of its termination in such time and manner as to affd a reasonable opptunity to act on it. Please complete all applicable infmation: Net to Checking Net to Savings $ to Checking $ to Savings $ to Checking $ to Savings Bank Name: Branch Address: Branch Phone: Account Number: ACH Routing Number:* * Obtain from bank * Obtain from bank * Obtain from bank ** If possible, please attach a copy of a blank voided check from account. *** Fward to Payroll Department, Financial Services Building *** It generally takes two complete payroll periods to begin direct deposit. Employee Name ID # - - Please Print Employee signature required dd.frm 11/2/99

5 CLGS-32-6 (8-11) RESIDENCY CERTIFICATION FORM Local Earned Income Tax Withholding TO EMPLOYERS/TAXPAYERS: This fm is to be used by employers and/ taxpayers to rept essential infmation f the collection and distribution of Local Earned Income Taxes. This fm must be utilized by employers when a new employee is hired when a current employee notifies employer of a name and/ address change. NAME (Last Name, First Name, Middle Initial) EMPLOYEE INFORMATION - RESIDENCE LOCATION SOCIAL SECURITY NUMBER STREET ADDRESS (No PO Box, RD RR) SECOND LINE OF ADDRESS CITY STATE ZIP CODE DAYTIME PHONE NUMBER MUNICIPALITY (City, Bough Township) COUNTY RESIDENT PSD CODE TOTAL RESIDENT EIT RATE EMPLOYER BUSINESS NAME (Use Federal ID Name) EMPLOYER INFORMATION - EMPLOYMENT LOCATION EMPLOYER FEIN STREET ADDRESS WHERE ABOVE EMPLOYEE REPORTS TO WORK (No PO Box, RD RR) SECOND LINE OF ADDRESS CITY STATE ZIP CODE PHONE NUMBER MUNICIPALITY (City, Bough Township) COUNTY WORK LOCATION PSD CODE WORK LOCATION NON-RESIDENT EIT RATE CERTIFICATION Under penalties of perjury, I (we) declare that I (we) have examined this infmation, including all accompanying schedules and statements and to the best of my (our) belief, they are true, crect and complete. SIGNATURE OF EMPLOYEE DATE (MM/DD/YYYY) PHONE NUMBER ADDRESS F infmation on obtaining the appropriate MUNICIPALITY (City, Bough, Township), PSD CODES and EIT (Earned Income Tax) RATES, please refer to the Pennsylvania Department of Community & Economic Development website:

(Please Print using Black or Blue Ink) SEX: GENDER IDENTITY: MARITAL STATUS: SINGLE MARRIED OTHER

PATIENT INFORMATION (Please Print using Black or Blue Ink) LAST NAME: FIRST NAME: MIDDLE INITIAL: ADDRESS: CITY: STATE: ZIP: SEX: GENDER IDENTITY: MARITAL STATUS: SINGLE MARRIED OTHER RACE (OPTIONAL):