Pa New Hire Form – Fill Out and Use This PDF

Pennsylvania New Hire Reporting Program

New Hire Reporting Form

COMMONWEALTH OF PENNSYLVANIA

Center for Workforce Information & Analysis

Department of Labor & Industry

REQUIRED EMPLOYER INFORMATION:

REQUIRED EMPLOYEE INFORMATION: (Please type or print LEGIBLY in blue or black ink ONLY)

(Please type or print LEGIBLY in blue or black ink ONLY)

ONE EMPLOYEE PER BOX

Employer FEIN:

Employee Social Security Number

Employer Name:

Legal Name (First)

(Middle)

(Last)

Employer Address (Street, City, State, Zip):

PO Box’s are not acceptable

Street Address (Post Office Box is not acceptable)

Apartment Number (if available)

Employer Contact Name:

Zip Code

City

State

Employer Contact Phone Number:

Date of Hire (MM/DD/YYYY)

Date of Birth (MM/DD/YYYY)

Employer Contact Fax Number:

(Must be within 3 years of current date)

ONE EMPLOYEE PER BOX

Employer Contact Email:

Employee Social Security Number

Please fax this form to:

866-PAHIRES (866-748-4473) (TOLL FREE)

Legal Name (First)

(Middle)

(Last)

Or 717-657-HIRE (717-657-4473) (Local)

Street Address (Post Office Box is not acceptable)

Apartment Number (if available)

Or mail this form to:

Commonwealth of Pennsylvania

Zip Code

City

State

New Hire Reporting Program

P.O. Box 69400

Date of Hire (MM/DD/YYYY)

Date of Birth (MM/DD/YYYY)

Harrisburg, PA 17106-9400

(Must be within 3 years of current date)

Questions?

ONE EMPLOYEE PER BOX

Contact New Hire Customer Service at 888-PAHIRES (888-724-4737)

Employee Social Security Number

Or by email at: RA-LI-CWDS-NewHire@pa.gov

Legal Name (First)

(Middle)

(Last)

This form may be duplicated as needed

Save time and postage costs.

Street Address (Post Office Box is not acceptable)

Apartment Number (if available)

Online reporting is fast, free and paperless.

Zip Code

City

State

For more information about how to get started, please visit

www.pacareerlink.state.pa.us

Date of Hire (MM/DD/YYYY)

Date of Birth (MM/DD/YYYY)

(Must be within 3 years of current date)