Douglas A. Ducey                                                                                                                          Michael Trailor
Governor                                                                                                                                   Director 

                                        New Hire Reporting Form 

Mail: Arizona New Hire Reporting Center                                                                                                                    Fax: 1-888-282-0502 
PO Box 142901 Austin TX 78714                                                                                                             Report online at www.az-newhire.com

                                                EMPLOYER INFORMATION 
                                                    *REQUIRED INFORMATION

*Federal Employer Identification Number (FEIN)-the same FEIN used to report quarterly wages:
__________________________________________________________________________________________________
*Employer Name:                                          DBA: 
__________________________________________________________________________________________________ 
*Contact Name:
__________________________________________________________________________________________________
*Payroll Address-address where an Income Withholding Order may be sent:
__________________________________________________________________________________________________

*City: ______________________________ *State: _______________ *Zip Code: _______________ Zip 4: ____________

Telephone:                                                          Fax:                                                           Email: 
__________________________________________________________________________________________________ 

Does employer offer Medical Insurance Benefits? Yes ________  No _________ 

                                                  EMPLOYEE INFORMATION 
                                        Complete one entry for each new employee 
                                                    *REQUIRED INFORMATION

*Social Security Number: ________________-_________________-________________
*Employee First Name: _________________________ M.I.: ________ Last Name: _________________________________
*Employee Address: __________________________________________________________________________________
*City: _______________________________________ *State: ____________ *Zip Code: _____________ +4:__________
*Date of Hire (First day of work): ________________________              Medical Insurance Available? Yes _______ No ________
Date of Birth: ___________________________  Employee Salary (Use decimal point if including cents): __________________
Pay Frequency-Please indicate: H=Hourly; B=Bi-Weekly; W=Weekly; S=SemiMonthly; M=Monthly; Y=Yearly  _____________

*Social Security Number: ________________-_________________-________________
*Employee First Name: _________________________ M.I.: ________ Last Name: _________________________________
*Employee Address: __________________________________________________________________________________
*City: _______________________________________ *State: ____________ *Zip Code: _____________ +4:__________
*Date of Hire (First day of work): ________________________              Medical Insurance Available? Yes _______ No ________
Date of Birth: ___________________________  Employee Salary (Use decimal point if including cents): __________________
Pay Frequency-Please indicate: H=Hourly; B=Bi-Weekly; W=Weekly; S=SemiMonthly; M=Monthly; Y=Yearly  _____________

                                        Arizona New Hire Reporting Center  PO Box 142901 Austin TX 78714 
                                        Telephone 888-282-2064   Fax 888-282-0502  www.az-newhire.com