Summary: Payroll Services Form for Approved
Non-University Affiliate Organizations
The information provided below has been supplied for the purpose of processing payroll for an individual who is not a
university employee. All regulated deductions will be automatically taken each month from the monies stipulated
below. Completed forms must be received by Human Resources (including Financial Services budget approval)
by the 15 of the monthth
*Payroll ID Number: S.I.N.: Gender: Date of Birth:
Title: *Surname: * Given Name: Initial:
City: Province: Country: Postal Code:
Attach a Void Cheque to the first Payroll Services Form submitted for a person or if a person's banking information changes.
I hereby authorize the release of the above information to Queen's University for the purposes of processing payroll. I understand that I am not
a Queen's University employee and that my employment, including the terms and conditions of employment are solely the responsibility of the
above hiring organization.
(blue ink only)