Maria Z. Moore
Southampton Town Supervisor

Juan Becerra
Deputy Director of Human Resources

Department of Human Resources
116 Hampton Road Southampton, NY 11968, NY 11968 Phone (631) 287 - 5715 Fax (631) 287 - 5721

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Part Time Form - Department submission to Comptroller's Office

EMPLOYEE INFORMATION

Requested On +

First Name

Mid. I.

Last Name

New Hire 🛈

Former Title

Previous Rate

Current Rate *

Total Hours *

Amount Funding
(automatically calculated)

0.00

Employee Age *

Under 18

Over 18

Employment Type

Employment Title - Part Time

Employment Title - Seasonal

Employment Title - Lifeguard

Start Date +

End Date +

Location

Driver

Submitted By
(Please enter your email address below) *

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