TEXAS THRONE LLC
340
LEMA
78374
(361) 81 6-8979
PORTLAND,
PORTABLE
TEXAS
RESTROOM
& SERVICE
RENTAL
Equal accessto programs, servicesand employment is availableto all persons; Those applicants requiring reasonable accommodation to the
plication and/or Ineerviewprocess should notify a represemarive of the Human Resources Depamnent.
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If you are under 18,and it is required, can you furnish a work permit?
If no, ~easeap~
0 Yes 0 No
_
Have you ever been employed here befure? Ifyes, give dates and positions
Are you legally eligible ror employment in this counny?
Date available for work
I
I
What is your desired salary range?
Type of employment desired
D Full-Time
D Part-Time
0 Temporary
Driver's license number if driving may be required in position for which you are applying
"
:
0 Seasonal
0 Yes
DYes
DNo
DNo
$
_
0 Educational Co-Op
State
_
Answering "yes" to the following questions does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the
violation, rehabilitation and position applied for will be taken into account. .
Have you ever pled "guilty" or "no contest" to, or been convicted of a ~e?
If yes, please provide datets) and details
.. Employment
HistorY
0 Yes
.
..
D No
_
.
Starting with your most recent employer, provide the following information,
Employer
Telephone i
Street address
Gty
t
to
SlatE
DHnurIy
Starting job title!finaljob
y..,
-/
-/
1$
Ds.wy
title
per
$
Immediate supervisor and title (toT III<lSt reamt position ~)
Summarin the type of work pMonned and job responsibilities-
What did you like most about your position?
What were tile tllings yo~
lliieil ieast aJJOOtIIH!~?
Employer
lelephon.
Street address
City
1/ }
-/
Dales employed:
State
o
Starting job titfe/final job titfe
Hourly
Year
to
-/
Year
DSalaly
per
$
!!;Iy we CD!IIact toT reference?
No
later
Immediate supervisor and titfe (for most recent position held)
I Dyes
Why did you leave?
D
D
D Hourly
0
Commission/8onus/Il!her
s.IaJy
per
$
Compensation
Summarize iii. type of wmIc performed and job responsibiliti05.
What did you like most about your position?
What were IIH!tlrings you 6kei1
teaSt
about tile position?
Employer
Street address
Stamng job title/finaljob title
r=:
Dates
State
Gty
~..
'
Immediate supervisor
and title (fur most ll!a!I1t position held)
Why did you 1save1
.'
:
employed:
-/
y•••.
to
Month
Year
/
o Hourly
0 SaI.aJy
I$
per
o Hourly
0 Sala'Y
l$
per
,-.
Wl1atdid you Hke most alIOut your po<ition?
.
",.
-,,'~'
. .
,"
Skills and- Qualifications
'.k
.
_
Summarize any special training, skills, licenses and/or certificates th:lt may assist ~u in performingthe position for which you are applying.
Computer Skills (Check appropriate boxes. Include software titles and years of experience.)
o Word
Processing
o Spreadsheet
o Presentation
Years:
0 E-mail
years:___
0 Internet
~~
0 Other
~---years:--·-
" Educational Background.
__
Years:
_
Years:
_
Years:
_
~
. _
.
-.
-
. '.
_
starting with your most recent school attended. provide the following informatio.n.
D 0ipI0ma D liED
D Degree
D Certfficatlon
-:--
_
_
DOIfIer
D Diploma
. D 6ED
D Degree _-'--'-_-'Certilication_.:....-
__
o
t:
DOtfIer
."j
D Diploma
DDegree
D liED
_
DCertilication
_
DOIfIer
.~~eferences
. ._ _
.
:
_.-'
.
~
....
List name and telephone number of three business/work references who are not related to you and are not previous supervisors.
If not applicable, list three school or personal references who are not related to YOlL
Applicant Statement
-
(
)
(
)
.
_
I certify that all information I have provided in order to apply fOr and secure wade with this employer is true, complete and correct,
I expressly authorize, without reservation, the employer, its representatives, employees or agt:nts to contact and obtain information from all references (personal and
professional), employers. public agencies, licensing authorities and educational institutions and to otherwise verifY the aa:wacy of all information provided by me in this
application, resume Or job interview. I hereby waive any and all rights and claims I may have n:garrling the employer, its agents, employees or representatives, for seeking.
gathering and using truthful and non-ddiunatory information, in a lawful manner, in the employment process and all other penons, corporations or organizations fOr
fiunishing such informacion about me.
I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any
applicant from consideration for employment on any basis prohibited by applicable local, state or fedcrallaw.
I understand that this application remains current for only 30 days. AI. the conclusion of that time, if I have not heard from the employer and still wish to be considered for
employment, it will be necessary for me to reapply and fill our a new application.
If I am hired, I understand that I am free m resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminare my
employment at any time, with or without cause and with or without prior notice, excepr as may be required by law. ibis application does nor constitute an agreement or contract
for employment fOr any specified period or de6nite duration.. I understand that no supervisor or representative of the employer is authorized [0 make any assurances to the
conrrary and that no implied oral or written agreements conrrary to the foregoing cxpn:ss language are valid unless they are in writing and signed by the employer's president.
I also understand that if I am hired, I will be required to provide proof of identity and lc:gal authorization to work in the Unired States and that federal immigcttion laws
require me to complete an 1-9 Form in this regard.
•
.
I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect. will be sufficient cause to (i) eliminate me
from further consideration for employment, or (fi) may result in my immediate discharge from the emplnyers service, whenever it is discovered.
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mool G.NcB
720 Intcnutiorul P1rkw.ay. Sunrise'. fL 33325
800-999--9111·
--sncil.c:om coreonkr
IIppliAlion for Emp'."""" (Sbon Fono) #R-I-A08Z7
-
Complete all worksheets that apply. However,
you may claim fewer (or zero) allowances. For
regular wages, withholding must be based on
allowances you claimed and may not be a flat
amount or percentage of wages.
Head of household. Generally, you may claim
head of household filing status on your tax return
only if you are unmarried and pay more than
50% of the costs of keeping up a home for
yourself and your depenclent(s) or other
qualifying individuals. See Pub. 501, Exemptions,
Standard Deduction, and Filing Information, for
information.
Tax credits. You Can take projected tax credits
into account in figuring your allowable number of
withholding allowances. Credits for child or
dependent care expenses and the child tax
credit may be claimed using the Personal
Allowances Wor1csheet below. See Pub. 919,
How Do I Adjust My Tax Withholding, for
information on converting your other credits into
Form W-4 (2011)
Purpose. Complete Form W-4 so that your
employer can withhold the correct federal
income tax from your pay. Consider completing a
new Fonn W-4 each year and when your
personal or financial situation changes.
Exemption from withholding. If you are exempt,
complete only lines 1, 2, 3, 4, and 7 and sign
the form to validate it. Your exemption for 2011
expires February 16,2012. See Pub. 505, Tax
Withholding and Estimated Tax.
Note. If another person can claim you as a
dependent on his or her tax return, you cannot
claim exemption from withholding if your income
exceeds $950 and includes more than $300 of
unearned income (for example, interest and
dividends).
Basic instructions. If you are not exempt,
complete the Personal Allowances Worksheet
below. The worksheets on page 2 further adjust
your withholding allowances based on itemized
deductions, certain credits, adjustments to
income, or two-earners/multiple jobs situations.
Enter "1» for yourself
Two earners or multiple jobs. If you have a
working spouse or more than one job, figure the
total number of allowances you are entitled to
claim on all jobs using worksheets from only one
Form W-4. Your withholding usually will be most
accurate when all allowances are claimed on the
Form W-4 for the highest paying job and zero
allowances are claimed on the others. See PUb.
919 for details.
Nonresident alien. If you are a nonresident alien,
see Notice 1392, Supplemental Form W-4
Instructions for Nonresident Aliens, before
completing this form.
Check your withholding. After your Form W-4
takes effect, use Pub. 919 to see how the
amount you are having withheld compares to
your projected total tax for 2011. See Pub. 919,
especially if your earnings exceed $130,000
(Single) or $180,000 (Married).
withholding allowances.
Nonwage income. If you have a large amount of
nonwage income, such as interest or dividends,
consider making estimated tax payments using
Personal Allowances
A
Form 104O-ES, Estimated Tax for Individuals.
Otherwise, you may owe additional tax. If you
have pension or annuity income, see Pub. 919 to
find out if you should adjust your withholding on
Form W-4 or W-4P.
Worksheet
if no one else can claim you as a dependent
(Keep for your records.)
A
.
• You are single and have only one job; or
B
Enter "1" if:
{
}
B
• You are married, have only one job, and your spouse does not work; or
• Your wages from a second job or your spouse's wages (or the total of both) are $1,500 or less.
Enter "1" for your spouse.
C
But, you may choose to enter "-0-" if you are married and have either a working
than one job. (Entering "_0_" may help you avoid having too little tax withheld.)
D
Enter number of dependents
E
Enter "1" if you will file as head of household
(Note. Do not include child support
Child Tax Credit
G
on your tax return (see conditions
child plus "1" additional
care expenses
under Head of household
D
E
above)
F
for which you plan to claim a credit
See Pub. 503, Child and Dependent
Care Expenses,
for detalls.)
child tax credit). See Pub. 972, Child Tax Credit, for more information.
$61,000 ($90,000
• If your total income will be between
Add lines A through
For accuracy,
(
complete all
worksheets
that apply
•
payments.
Qncluding additional
• If your total income will be less than
H
C
(other than your spouse or yourself) you will claim on your tax return .
Enter "1" if you have at least $1,900 of child or dependent
F
spouse or more
.
if married), enter
$61,000 and $84,000
"2" for each eligible child;
($90,000 and $119,000
if you have six or more eligible children
then less
"1" if you have three or more eligible
children .
if married), enter "1" for each eligible
G
.
G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.) •
H
see the Deductions
• If you plan to itemize or claim adjustments
to income and want to reduce your withholding,
and Adjustments
Worksheet
on page 2.
• If you have more than one job or are manied and you and your spouse both work and the combined earnings from all jobs exceed
$40,000 ($10,000 if married). see the Two-EamerslMultiple Jobs Worksheet on page 2 to avoid having too litHetax withheld.
• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.
--.-----------------------------
Cut here and give Form W-4 to your employer.
W-4
Keep the top part for your records.
-----------.------------------.
Employee's Withholding Allowance Certificate
OM8 No. 1545-0074
Form
• Whetheryou are entitled to claim a certain number of aBowances or exemption from withholding is
Department
of the Treasury
subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
InternalRevenue
SeMce
1
Iype or print your first name and middle initial.
last name
Your social security number
~@11
1
12
Home address (number and street or rural route)
3D
Single
Note. If married,
City or town, state, and ZIP code
5
6
Additional
7
I claim exemption
Total number of allowances
amount,
o Married 0
but
Married, but withhold at higher Single rate.
legallyseparated,
or spouseis a nonresident
alien,check the·Single"box.
4 Ifyour last name differs from that shown on your social security card,
check here. You must call 1-800-772-1213 for a replacement card .•
you are claiming
if any, you want withheld
(from line H above or from the applicable
worksheet
on page 2)
from each paycheck
0
5
6 $
from withholding for 2011, and I certify that I meet both of the following conditions for exemption.
• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability and
• This year I expect a refund of all federal income tax withheld
If you meet both conditions, write "Exempt" here.
because
I expect to have no tax liability .
..
• 171
Under penalties of PerJury,Ideclare that Ihave examined this certificate and to the best of my knowledge and bebef,It IStrue, correct, and complete.
Employee's Signature
(This form is not valid unless you sign it.) ~
6
Employer's name ana address (Employer:Complete lines 8 and 10 only if sending to the IRS.)
For Privacy Act and Paperwork
Reduction
Act Notice, see page 2.
10
Cat. No. 102200
Employer identificationnumber(E
Form W -4 (2011)
Page 2
Form W-4 (2011)
Deductions and Adiustments
Worksheet
Note. Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments
1
2
3
4
5
Enter an estimate of your 2011 itemized deductions.
These include qualifying home mortgage interest,
charitable contributions,
state and local taxes, medical expenses in excess of 7.5% of your income, and
miscellaneous deductions
.
$11,600 if married filing jointly or qualifying widow(er)
}
Enter: { $8,500 if head of household
$5,800 if single or married filing separately
Subtract line 2 from line 1. If zero or less, enter" -0Enter an estimate of your 2011 adjustments to income and any additional standard deduction (see Pub. 919)
Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to
Withholding Allowances for 2011 Form W-4 Worksheet in Pub. 919.)
D
6
Enter an estimate
of your 2011 nonwage
income (such as dividends
or interest)
.
7
Subtract
8
Divide the amount on line 7 by $3,700 and enter the result here. Drop any fraction
9
Enter the number from the Personal Allowances
Worksheet,
line H, page 1 .
Add lines 8 and 9 and enter the total here. If you plan to use the Two-Eamers/Multiple
10
to income.
line 6 from line 5. If zero or less, enter" -0-"
also enter this total on line 1 below. Otherwise,
Two-EamersIMultiple
$
3
4
$
$
5
6
7
8
9
$
$
$
10
under line H on page 1 direct you here.
Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjusbnents
2
Find the number
1 below that applies to the LOWEST
Worttsheet)
paying job and enter it here. However,
you are married filing jOintly and wages from the highest paying job are $65,000
1
if
or less, do not enter more
than "3"
3
2
Jobs Worksheet,
stop here and enter this total on Form W-4, line 5, page 1
1
in Table
$
Jobs Worksheet (See Two earners or multiple jobs on paqe 1.)
only if the instructions
Note. Use this worksheet
1
2
If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here [rt zero, enter
"-0-1 and on Form W-4, line 5, page 1. Do not use the rest of this worksheet.
Note. If line 1 is less than line 2, enter "-()-" on Form W-4, line 5, page 1. Complete
withholding amount necessary to avoid a year-end tax bill.
lines 4 through
Enter the number from line 2 of this worksheet
3
9 below to figure the additional
4
5
4
5
6
Subtract
7
Find the amount in Table 2 below that applies to the HIGHEST
8
Multiply
9
Divide line 8 by the number of pay periods remaining in 2011. For example, divide by 26 if you are paid
every two weeks and you complete this form in December 2010. Enter the result here and on Form W-4,
line 6, page 1. This is the additional amount to be withheld from each paycheck
Enter the number from line 1 of this worksheet
line 5 from line 4 .
6
paying job and enter it here
line 7 by line 6 and enter the result here. This is the additional
annual withholding
needed
Table 1
Married
Filing Jointly
If wagesfrom LOWEST
payingjob are$0 - $5,000
5,001 - 12,000
12,001 - 22,000
22,001 - 25,000
25,001 - 30,000
30,001 - 40,000
40,001 - 48,000
48,001 - 55,000
55,001 - 65,000
65,001 - 72,000
72,001 - 85,000
85,001 - 97,000
97,OOl -110,000
110,001 -120,000
120,001 -135,000
135,001 and over
-
°
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
If wagesfromLOWEST
payingjob are$0
8,001
15,001
25,001
30,001
40,001
SO,OOl
65,001
80,001
95,001
120,001
$
$
9
$
Table 2
Married Filing Jointly
All Others
Enteron
line 2 above
7
8
- $8,000
- 15,000
- 25,000
- 30,000
- 40,000
- SO,ooo
- 65,000
- 80,000
- 95,000
-120,000
and over
-
-
Enteron
line 2 above
°
1
2
3
4
5
6
7
8
If wages from HIGHEST
paying job are$0
65,001
125,001
185,001
335,001
-
$65,000
125,000
185,000
335,000
and over
Enteron
line 7 above
$560
930
1,040
1,220
1,300
All Others
If wages from HIGHEST
paying job are$0
35,001
90,001
165,001
370,001
- $35,000
- 90,000
- 165,000
- 370,000
and over
Enteron
line 7 above
$560
930
1,040
1,220
1,300
g
10
Privacy Act andPaperworloReductionAct Notice.Weaskforthe information on!hisfonnto
carryouttheInternalRevenuelawsof theUnitedStates.InternalRevenueCodesections
3402(1)(2) and6109 andtheirregulations
requireyouto providethisinfonnation;youremployer
usesit to determineyourfederalincometaxwithholding.Failureto providea properly
completedformwmresultin yourbeingtreatedasa singlepersonwhoclaimsnowithholding
allowances;
providingfraudulentinfonnationmaysubjectyouto penalties.Routineusesof this
informationincludegivingit to theDepartment
ofJusticefor civilandcriminallitigation,to
cities,slates,theDistrictof Columbia,andU.S.commonwealths
andpossessions
for usein
administering
theirtax laws;andto theDepartment
of HeatthandHumanServicesfor usein
theNationalDirectoryof NewHires.WemayalsodisclosetI1sinlomlationto othercountries
underataxtreaty,to federaland stateagenciesto enforcefederalnontaxcriminallaws,orto
federallawenforcement
andintelligence
agenciesto combatterrorism.
You are not requiredto provide the information requested on a form that is
subject to the Paperwork Reduction Act unlessthe form displays a valid OMS
control number. Books or records relating to a form or its instructions must be
retained as long as their contents may become material in the administration of
any InternalRevenuelaw. Generally,tax returns and return information are
confidential, as required by Code section 6103.
The average time and expenses required to complete and file this form will vary
depending on individual circumstances. For estimated averages, see the
instructions for your income tax retum.
If you have suggestions for making this form simpler, we would be happy to hear
from you. See the instructions for your income tax return.
OMB No. 161.5-0047; Expires 08131/12
Form 1-9, Employment
Department of Homeland Security
Eligibility Verification
U.S. Citizenship and Immigration Services
Read instructions carefully before completing tbis form. The instructions must be available during completion of this form.
ANTI-DISCRIMlNA TION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT
specify which document(s) they wiD accept from an employee. The refusal to hire an individual because the documents have a
future expiration date may also constitute illegal discrimination.
Section 1. Employee Information
Print Name:
and Verification (To be completed and signed by employee at the time emolovment begins.)
Last
First
Middle Initial
Address (Street Name and Number)
Slate
City
Maiden Name
Apt. #
Date of Birth (month/day/year)
Zip Code
Social Security #
I attest, WIder penalty of perjury, that I am (check one of the following):
o
I am aware that federal law provides for
imprisonment and/or fines for false statements or
use of false documents in connection with the
completion ofthis form.
o
o
o
A citizen of the United States
A noncitizen national of the United States (see instructions)
A lawful permanent resident (Alien #)
_
An alien authorized 10 work (Alien # or Admission #)
until (exniration date, if annlicable - month/dav/veart
Employee's Signature
Date [month/day/year}
Prepa rer and/or Translator Certification (To be completed and signed if Section 1is prepared by a person other than the employee.) I attest, under
penalty of perjury, that [ have assisted in the completion of this form and that 10 the best of my mawledge the information is true and correct.
Preparer's/Translator's
Signature
Print Name
Date [month/day/year}
Address (Street Name and Number, City, State, Zip Code)
Section 2. Employer Review and Verification (To be completed and signed by employer. Examine one documentfrom List A OR
examine one document from List B and one from List C, as listed on the reverse of this form, and record the title, number, and
expiration date, if any, of the document(s).)
List A
OR
List B
AND
List C
Document title:
Issuing authority:
Document#:
Expiration Date (if any):
Document#:
Expiration Date (if any):
CERTIFICATION: I attest, under penalty of perjury, thatl have examined the document(s) presented by the above-named employee, that
the above-listed document(s) appear to be genuine and to relate to the employee named, that the employee began employment on
(month/day/year)
and that to the best of my knowledge the employee is authorized to work in the United States. (State
employment agencies may omit the date the employee began employment.)
Signature of Employer or Authorized Representative
Print Name
Title
Business or Organization Name and Address (Street Name and Number, City, State, Zip Code)
Section 3. Updating and Reverification
Date (month/day/year)
(To be completed and signed by employer.)
A. New Name (if applicable)
B. Date of Rehire (month/daylyear)
(if applicable)
C. If employee's previous grant of work authorization has expired, provide the information below for the document that establishes current employment authorization.
Document Title:
Document #:
Iattest, under penalty of perjury,
documcnt(s).
tbe document(s)
that to tbe best of my knowledge, tbis employee is autborized
I bave examined
appear
Signature of Employer or Authorized Representative
to be genuine
aDd to relate
Expiration Date (if any):
to work in the United States, and if tbe employee presented
to tbe iDdividuaL
Date (month/day/year)
Form 1-9 (Rev. 08/07/09) Y Page 4