ETR Employer Back-to-Work Form

Employer Back-to-Work Form

As part of our agreement with employers, we request information from your company/organization when you hire an individual. ETR requires accurate up-to-date information in order to continue to provide this service at no cost to you and others. Thank you for your cooperation.

To whom at ETR would you like this information sent?

Company Information
Company Name
Contact Name
Telephone (including extension)
E-mail Address

New Hire Information
Job Order Number
New Employee Name
Last 4 digits of SSN
Address
City
State
Zip
Phone
Job Start Date
Job Title
Pay	Per Plus Commission Plus Tips
Hours Per Week
Is This a Permanent Position?	Yes No If Temporary, for how long?
Company Benefits Available For This Job (Please check all that apply)	No Benefits 401K Bonuses Child Care Referral Resources Child Care Services Reimbursement Clothing Allowance Dental Insurance Education Cost Reimbursement Employee Discount In_House Skills Training Programs Life Insurance Long Term Disability Major Medical Mileage Reimbursement	On_Site Child Care Paid Holidays Prescriptions Retirement Plan Short Term Disability Sick Leave Subsidized Skills Development (e.g., ESOL, Adult Education) Uniforms Furnished Vacation Leave Vehicle Furnished Vision Insurance Other (Please specify)
Comments?

Thank you for taking the time to share this important information with us.

If you experience problems with this form, please consider using the MS Word version of the form, or contact Diane for assistance
(781-769-4120, ext 114, DMarvelle@detma.org)

Page last updated on March 27, 2008

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