California Polytechnic State University Foundation

CAL POLY CORPORATION Payroll Information Form (P.I.F.) Legal Last Name: Legal First Name: M.I.: SS #: Sex:  Male  Female

Address for W2: (Street, City, State and Zip) Birth Date:

Badge # (If applicable) Cal Poly Email (or other if you do not have a Cal Poly email): Primary Phone Number:

Are you currently working on campus?  Yes  No If yes, where? (Check all that apply)  State  Cal Poly Corporation  ASI

CHECK APPROPRIATE ACTION INDICATE YOUR EMPLOYEE STATUS BELOW ANSWER QUESTIONS BELOW Do you have a close family member working for CPC or CPSU? If yes, list name & relationship below:  New Hire _____/_____/_____  Cal Poly Student * (limited to 20 hours/week) Name:______Relationship: ______ Termination  Undergraduate (minimum 6 units) (Note, a close family member may not work directly for a relative.) Last Day Worked: _____/_____/_____  Graduate (minimum 4 units) Do you require any accommodations to do this job?  No  Yes  Intermittent **(limited to 999 hours per FY/CY) Reason:______If so, indicate:______Add Comp ***(addt’l 25% time maximum; no FERP)  Status Change (check all that apply)  CPSU Staff (F/T)  Exempt  Non-exempt  Primary Assignment Please list crime convictions (exclude minor traffic infractions &  Add Org Key/Account(s)  CPSU Faculty (F/T)  Exempt  Non-exempt judicially dismissed or ordered sealed convictions). Include DUI.  Rate (no retroactive changes allowed)  CPSU Employee (Part-time)  Lecturer  Staff  End Date  Retiree  CPSU  CPC  Other ______ Address Change  Provisional Have you been discharged?  Yes  No If yes, give details below:  Other ______ CPC Benefited  Mail Check: ______Title (check is mailed to W-2 address) ARE YOU A CALPERS MEMBER?  YES  NO Comments: * Students are limited to 20 hours per week during the academic year & up to full-time during summer & quarter breaks, but no more than 1400 hours/CY. ** Intermittent employees may not work more than 25 hours per week or 999 hours per fiscal year (7/1 – 6/ 30) or calendar year (1/1 – 12/31). They are hired on an “as needed” basis only with a variable hour schedule. *** Full-time Faculty will not be paid beyond an average of 25% effort during an academic year, excluding quarter breaks. Full-time CPSU staff employees may work up to 10 hours/week for CPC. Part-time CPSU staff/faculty are limited to the lesser of F/T between CPSU & CPC or 999 hours per FY or CY. W/C Code Effective End Date Pay Rate W/C Effective End Date Pay Code  (if applicable) Org Key Account  Date (if applicable) (hourly) Org Key Account Date Rate

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All pay rates must be hourly except for CPC benefited Exempt Staff which are bi-weekly.

 W/C Codes: Admin/Clerical/Non-Manual = 1001 Agriculture/Manual Labor/Use of Machinery or Chemicals/Printing Press = 1007 Athletic Camps = 1005 Campus Dining = 1006 Professors /Tutors/Consulting/Performers/Offsite Non-Manual Research = 1002 Retail = 1004 PLEASE NOTE: All Cal Poly Corporation employment is “at will”; either the employee or the Cal Poly Corporation can terminate employment at any time with or without cause or notice. The Cal Poly Corporation retains the right to change conditions of employment such as wages, hours, position, etc. at any time at its sole discretion. CalPERS retirees are limited to 960 hours per fiscal year without retirement penalties. Faculty Early Retirement Program (FERP) retirees are ineligible for employment during the FERP. I hereby certify that all the information on this form is correct and complete to the best of my knowledge. I understand that falsification or omission of any material information on this form may be considered cause for immediate dismissal. STUDENTS ONLY: By signing below you certify that you are currently enrolled at Cal Poly for 6 or more units for undergraduate studies, 4 or more units for graduate studies. If you drop below the required number of units during the quarter, you must notify your supervisor and Cal Poly Corporation Human Resources.

EMERGENCY CONTACT: ______RELATIONSHIP: ______PHONE #______

Employee’s Signature: ______Date: ______

Authorized By (sign):______(Print name):______Tel #: ______Date: ______Dept. Head/Project Director/Supervisor Sponsored Programs/Conference Services/Other: Human Resources Director: ______

New employees must complete the I-9 and show documentation; typical is a passport OR a driver’s license & SS card. A W4 form is optional and Single-0 exemptions will be entered if no form is submitted. For the most up-to-date forms go to www.calpolycorporation.org; click on Forms & Procedures; click on Human Resources; and scroll down under Human Resources – Employment. For payroll deadlines or timesheets, please click on Payroll and check the most current Payroll Calendar. Rev 1/14