PDF document

- 1 -

                 NEW  MEXICO     NEW     HIRE        Mail Reports to:   
                                                     New Mexico New Hire  Directory    
                 REPORTING FORM                      PO     Box 2999     
                                                     Mercerville, NJ 08690   
                                        
                                                     Fax Reports to:  888-878-1614  
                                    
                          EMPLOYER    INFORMATION 

                          EMPLOYEEE    INFORMATION 
                                                                                              
  Toll     (888) 878-1607   www.NM-newhire.com        Toll Free Fax: (888) 878-1614 
   Free Phone:                                                                       
                                                                                             
                                                                               Rev. 06/19

PDF file checksum: 3250215093

(Plugin #1/9.12/13.0)

Removed Elements:

NEW MEXICO NEW HIRE REPORTING FORM
Send completed forms to:
Fax forms toll free:
1-888-878-1614

New Mexico New Hires Directory
Submit Online:
PO Box 29480
For more information:
1-888-878-1607

Santa Fe, NM 87592-9480

COMPANY INFORMATION
*Required Information
Federal Employer Identification Number* _____________________________________________________________

Company Name* _________________________________________________________________________________

Payroll Address* _________________________________________________________________________________

(Address where Income Withholding Orders should be sent)
City, State, Zip Code* _____________________________________________________________________________

Contact Name/Phone ______________________________________________________________________________

Contact/Company Email ___________________________________________________________________________

EMPLOYEE INFORMATION
*Required Information
Employee #1
Name* _______________________________________________________ Date of Hire* ________________

Social Security Number*_________________________________________ Date of Birth _________________

Address* _____________________________________________________ State of Hire _________________

City, State, Zip Code* ___________________________________________ Medical Insurance Available?

YES NO

Employee #2
Name* _______________________________________________________ Date of Hire* ________________

Social Security Number*_________________________________________ Date of Birth _________________

Address* _____________________________________________________ State of Hire _________________

City, State, Zip Code* ___________________________________________ Medical Insurance Available?

YES NO

Employee #3
Name* _______________________________________________________ Date of Hire* ________________

Social Security Number*_________________________________________ Date of Birth _________________

Address* _____________________________________________________ State of Hire _________________

City, State, Zip Code* ___________________________________________ Medical Insurance Available?

YES NO

PDF file checksum: 1841375964