New Hire Onboarding Information Request

EMPLOYEE NEW HIRE INFORMATION FORM
The following information is required to create a new hire record for your organization. This information is handled with HIPAA Compliance. Please do not print this form and attempt to hand-write the information in. Your signature will be captured electronically at the end of this form and you will receive a confirmation email upon submission. Thank you.
Today's Date

MonthDayYear
AM/PM Option
NEW HIRE INFORMATION
Company Name: *
Full Name*
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
E-mail Address*
Your personal email address, not work, is suggested for privacy.
Daytime Phone*

Area CodePhone Number
NEW HIRE IDENTIFICATION INFORMATION
Social Security Number*
Driver's License Number
Passport Number
Date of Birth*

MonthDayYear
Do you have any other current agreements in place?*

Not ApplicableNon-Disclosure Agreement (NDA)Severance AgreementEmployment AgreementPrior Offer Letter(s)Other agreement between you and our client choosing to hire you through Lightsource.Other
CERTIFICATION & SIGNATURE

The undersigned attests that the information contained in this document is true and correct to the best of the undersigned’s knowledge. The undersigned understands this document is not a contract for service or employment nor will it bind coverage of any kind. This information is gathered for statistical and actuarial use only. This information is not to be used in connection with any decisions or actions regarding any individual’s employment and is strictly governed by HIPAA compliance rules. In the event that information has been intentionally omitted or misrepresented, the employer of record may deny or limit coverage, furthermore, employment may be terminated. In compliance with requirements for GINA, Lightsource is not requesting genetic information. I will notify Lightsource of any changes to teh information imparted here that occur after signing this form.
Signature*

Clear
Sign on the line above with your mouse, stylus, or finger if mobile.
Should be Empty:

EMPLOYEE NEW HIRE INFORMATION FORM

NEW HIRE INFORMATION

NEW HIRE IDENTIFICATION INFORMATION