Employee Demographics

"*" indicates required fields

Name*

First Name Last Name

Social Insurance Number*

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Date of Birth*

Marital Status

Gender

Emergency Contact

Name*

Relationship*

Phone*

Banking Information

Direct Deposit Information*

Accepted file types: jpg, jpeg, png, gif, , Max. file size: 8 MB.

Please attach an unsigned, voided cheque image

Parking Pass Information

Parking Privileges Request*

Apply for Parking Privileges

Decline Parking Privileges

Cancel Parking Privileges

I understand that an established amount will be deducted from my pay cheque and that the fee may change from time to time according to economic conditions. The fee in effect at the present time may be obtained from the Payroll Department.

I understand that cars parked on the premises without a parking tag will be towed away at the employee’s expense. I understand that staff are not permitted to park in the visitor or emergency/out patient areas and that parking in these areas will result in disciplinary action and/or suspension for violation of Authority policy.

I understand that I am to notify the Payroll Department of any vehicle changes so that accurate records can be maintained.

List

Vehicle Make

Color

License #

Parking Tag #

I elect to contribute to the Five Dollar Club?*

Yes

Comments

This field is for validation purposes and should be left unchanged.

Below please find additional forms and information, please note that these are not required to be completed and submitted unless you choose to do so:

IERHA Payroll Calendar

TD1 Form – Provincial

TD1 Form – Federal

Guide To Viewing Pay Statements Online

Five Dollar Club Sign Up

Manitoba Blue Cross iCBT Information Sheet

How to Apply for Jobs on QSS