Employee Check Request Your check will NOT be processed unless you completely fill out the form below and hit submit to send it to our offices. Home Store #*17885 - Colfax32702 - Florin47 - Fruitridge33506 - Galleria Mall (Roseville)13923 - Lincoln31795 - Lincoln (2)36256 - Reno32133 - Rocklin3286 - Sparks17834 - Stanford Ranch6832 - Truckee30288 - Walmart (Roseville)1051 - Chico5354 - Chico12390 - Chico37011 - Chico39626 - Orland, CaHiddenOLD Home Store - Leave for previous entries. This field was first used to record store number but has been replaced by a dropdown. It has been left in place so that previously completed forms records are not expunged.HiddenRow 1HiddenSplit-StartDate Requested MM slash DD slash YYYY HiddenSplit-EndHiddenSplit-StartDate Check Needed MM slash DD slash YYYY HiddenSplit-EndEmployee Name First Last Time Card # Select one option below Terminated Quit Lost/ Stolen If they quit, what day did they give notice? Last actual day worked? Reason for leaving? How many hours to pay them for? (print& fax pay period report for the current pay run) Hidden Worked in other store/ ClassBorrowed Store# HiddenRow 2Hiddensplit-startDate Worked MM slash DD slash YYYY Hiddensplit-endHiddensplit-startHours Worked Hiddensplit-endHiddenRow 2Hiddensplit-startDate Worked MM slash DD slash YYYY Hiddensplit-endHiddensplit-startHours Worked Hiddensplit-endHiddenRow 3Hiddensplit-startDate Worked MM slash DD slash YYYY Hiddensplit-endHiddensplit-startHours Worked Hiddensplit-endPay Rate ChangeHiddenRow 5Hiddensplit-startOld Rate Hiddensplit-endHiddensplit-startNew Rate Hiddensplit-endDate to take effect MM slash DD slash YYYY Reason for rate change AuthorizationHiddenAuthorization Row 1Hiddensplit-startStore Manager First Last Hiddensplit-endHiddensplit-startSignature Please select this box to sign Hiddensplit-endHiddenAuthorization Row 2Hiddensplit-startSupervisor First Last Hiddensplit-endHiddensplit-startSignature Please select this box to sign Hiddensplit-end