This field is hidden when viewing the formOffice NotesName* First Last Email Last 4 of Social Security Number*Phone*Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you available for work?* YES NO OtherOtherAuthorizationBy signing below, you are saying that all of the above information is accurate and you are picking up YOUR W-2.Also, you are aware that you have 14 days to make Provide Staffing Services, LLC, aware that there are any corrections that need to be made to the check or direct deposit stub you are receiving on today's date.I* am picking up my W-2 want my w-2 mailed am authorizing someone else to pick up my W-2, and will put their name in the other box below OtherOtherSignature*Date* MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.Δ Please log into your account to view these forms.
