Data Change Form - TEL Staffing & HR

Client Company(Required)

Date(Required)

Employee Name(Required)

First Last

Payroll Changes

Effective pay period beginning date

New Rate of Pay

Untitled

Per Hour

Per Week

Per Bi-Weekly

Per Semi-Monthly

Per Month

Workers Comp Code

Title

Other Changes

If this change will affect your state withholding status, please contact TEL Staffing & HR Payroll Department at 850.476.9008.

Type of Change Request

Address Change

Phone Number Change

Name Change

Stop Direct Deposit

Other

Address

Street Address Address Line 2 City State ZIP Code

New Phone Number

Name

First Last

Must provide legal documentation

Financial Institution

Account Number

Routing Number

Other

Please explain in detail

Supervisor Email and Signature

Supervisor Email(Required)

Supervisor Signature(Required)

By typing your name on any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your “E-Signature”) is as valid as if you signed the document in writing.

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