Staffing, LLC
APPLICATION FOR EMPLOYMENT
DATE: ____/____/____
WE CONSIDER APPLICANTS FOR ALL POSITIONS WITHOUT REGARD TO RACE, COLOR, RELIGION, SEXUAL ORIENTATION, NATIONAL ORIGIN, AGE, CREED,
GENDER, MARITAL OR VETERAN STATUS, AND HANDICAP DISABILITY, THE PRESENCE OF A NON-JOB-RELATED MEDICAL CONDITION OR ANY OTHER
LEGALLY PROTECTED STATUS.
SEX OFFENDERS NEED NOT APPLY
PERSONAL INFORMATION
S.S. #______-______-______
Name:_________________________________________________________________________________
(First)
(Middle)
(Last)
Address:_______________________________________________________________________________
(Street)
(Apt. #)
_______________________________________________________________________________
(City)
(State)
(Zip Code)
Email Address:__________________________________________________________________________
Home Phone #:__________________________
Cell Phone #:________________________________
Emergency Contact:______________________
Emergency Contact #:_________________________
POSITION INFORMATION
Position(s) applying for:__________________________________________________________________
Days available to work (please circle)
Salary Desired: $________________
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
Minimum Rate willing to work for: $____________________
Willing to work (please circle all that apply)
TEMP
TEMP-TO-HIRE
PERM
Have you applied here before? __________ If yes, were you sent on assignment? ___________________
Are you currently employed? ___________ May we contact your present employer? _________________
Have you ever been convicted of a FELONY? (please check one) YES____________NO______________
If yes, please explain:
(Conviction will not necessarily disqualify applicant from employment)
EDUCATION
School
LOCATION
(city and state)
DATES
ATTENDED
DEGREE
OBTAINED
MAJOR
G.P.A.
EMPLOYMENT HISTORY
Company:
Address:
Phone :
Position Held:
City/State:
Industry:
Fax:
Supervisor’s Name:
Dates of Employment:
Ending Salary:
May we contact this employer?
Job Duties
Reason for Leaving
Company:
Address:
Phone :
Position Held:
City/State:
Industry:
Fax:
Supervisor’s Name:
Dates of Employment:
Ending Salary:
May we contact this employer?
Company:
Address:
Phone :
Position Held:
City/State:
Industry:
Fax:
Supervisor’s Name:
Dates of Employment:
Ending Salary:
May we contact this employer?
Job Duties
Reason for Leaving
Job Duties
Reason for Leaving
Company:
Address:
Phone :
Position Held:
City/State:
Industry:
Fax:
Supervisor’s Name:
Dates of Employment:
Ending Salary:
May we contact this employer?
Company:
Address:
Phone :
Position Held:
City/State:
Industry:
Fax:
Supervisor’s Name:
Dates of Employment:
Ending Salary:
May we contact this employer?
Job Duties
Reason for Leaving
Job Duties
Reason for Leaving
REFERENCES
Name
Relation
Telephone
Yrs. Known
I certify that the answers given herein are true and complete to the best of my knowledge. I authorize an
investigation of all statements contained in this application for employment as may be necessary in arriving
at an employment decision. I understand that neither this document nor any other offer of employment from
the employer constitutes an employment contract unless, a specific document to that effect, is executed by
the employer and me in writing. In the event of employment, I understand that false or misleading
information given in any application or interview(s) may result in discharge. I understand, also, that I am
required to abide by all rules and regulations of the employer.
Signed: ________________________________________________Date: _________________________
\
Staffing, LLC
CONFIDENTIAL INFORMATON
Name:_________________________________________________________________________________
Have you ever been convicted of a crime? ________YES ________NO
If yes, please explain:
____________________________________________________________________________________________
____________________________________________________________________________________________
List any Health/medical problems you now have which should be considered prior to assignment:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
List ANY medications that you are currently taking:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
**Some companies require drug testing therefore, you can be subject to drug testing.**
__________________________________________
Signature
_________________________
Date
Pre-Employment Inquiry Authorization Release
I. I understand that an investigative report may be generated on me that may include information as to my character, general reputation,
personal characteristics, or mode of living; work habits, performance or experience, along with reasons for termination of past
employment/professional license or credentials; financial/credit history; or criminal/civil/driving record history. I understand that USA
Intel, on behalf of (AT STAFFING, LLC) or its authorized agents may be requesting information from public and private sources about
any of the information noted earlier in this paragraph in connection with (AT STAFFING, LLC)’s consideration of me for employment,
promotion or position re-assignment or contract now, or at any time during my tenure with (AT STAFFING, LLC) and give my full consent
for this information to be obtained.
II. I acknowledge that a telephonic facsimile (FAX) or photographic copy of this release shall be as valid as the original. This release is valid
for most federal, state and county agencies.
III. I hereby authorize, without reservation, any financial institution, law enforcement agency, information service bureau, school, employer or
insurance company contacted by (USA INTEL, INC.) or our authorized agents, to furnish the information described in Section I.
APPLICANT – PLEASE COMPLETE THE FOLLOWING:
___________
__
Today’s Date
Signature
______
Print Name:
______
(First)
(Middle)
(Last)
(Maiden)
_______________________________________________________________________________________________________________
Other Names Used
Current Address Since:
_________
(Mo/Yr)
(State/Zip)
_________________________________________________________________________________
(Street)
(City)
Current Address Since:
_________
(Mo/Yr)
(State/Zip)
_________________________________________________________________________________
(Street)
(City)
Current Address Since:
_________
(Mo/Yr)
(State/Zip)
_________________________________________________________________________________
(Street)
(City)
The following information is required by law enforcement agencies and other entities for positive identification purposes when checking
public records.
It is confidential and will not be used for any other purposes.
Date of Birth
Social Security Number
Driver’s License Number and State
Have you ever been convicted of a crime? ___ No
Name as it appears on License
___ Yes
If yes, please provide city and state of conviction and details of conviction.
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
FAIR CREDIT REPORTING ACT NOTICE:
In accordance with the Fair Credit Reporting Act (FCRA, Public Law 91-508, Title VI), this information may only be used to verify a statement(s) made
by an individual in connection with legitimate business needs.
The depth of information available varies from state to state. Status of updates are available on request. Although every effort has been made to assure
accuracy, DirectScreening.com cannot act as guarantor of information accuracy or completeness. Final verification of an individual’s identity and proper
use of report contents are the user's responsibility. Our authorized agent, DirectScreening.com, has a policy that requires purchasers of these reports to
have signed a Service Agreement. This assures DirectScreening.com that users are familiar with and will abide by their obligations, as stated in the
FCRA, to the individuals named in these reports.
If information contained in this report is responsible for the suspension or termination of an employee or the application process, have the
Candidate/employee contact DirectScreening.com at 190 Haverhill Street, Methuen, MA 01844.
NOTICE TO CALIFORNIA CANDIDATES
You have a right to obtain a copy of any consumer report or investigative consumer report obtained by (enter company name here) by checking the box provided below. The report will be
provided to you within (3) business days after we receive the requested reports related to the matter investigated.
� I request to receive a free copy of this report by checking this box.
Under section 1786.22 of the California Civil Code, you may view the file maintained on you by DirectScreening.com during normal business hours. You may also obtain a copy of this file
upon submitting proper identification and paying the costs of duplication services, by appearing at DirectScreening.com in person or by mail. You may also receive a summary of the file by
telephone. The agency is required to have personnel available to explain your file to you and the agency must explain to you any coded information appearing in your file. If you appear in
person, a person of your choice may accompany you, provided that this person furnishes proper identification.
Form W-4 (2015)
Purpose. Complete Form W-4 so that your employer can
withhold the correct federal income tax from your pay.
Consider completing a new Form 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 2015 expires February 16,
2016. 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 $1,050 and
includes more than $350 of unearned income (for
example, interest and dividends).
Exceptions. An employee may be able to claim
exemption from withholding even if the employee is a
dependent, if the employee:
• Is age 65 or older,
• Is blind, or
• Will claim adjustments to income; tax credits; or
itemized deductions, on his or her tax return.
The exceptions do not apply to supplemental wages
greater than $1,000,000.
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 twoearners/multiple jobs situations.
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 can 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 dependent(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
Worksheet below. See Pub. 505 for information on converting
your other credits into withholding allowances.
Nonwage income. If you have a large amount of
nonwage income, such as interest or dividends, consider
making estimated tax payments using Form
1040-ES, Estimated Tax for Individuals. Otherwise, you
may owe additional tax. If you have pension or annuity
income, see Pub. 505 to find out if you should adjust
your withholding on Form W-4 or W-4P.
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 FormW-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. 505 for details.
Nonresident alien. If you are a nonresident alien, see
Notice 1392, Supplemental Form W-4Instructions for
Nonresident Aliens, before completing this form.
Check your withholding. After your Form W-4 takes
effect, use Pub. 505 to see how the amount you are
having withheld compares to your projected total tax
for 2015. See Pub. 505, especially if your earnings
exceed $130,000 (Single) or $180,000 (Married).
Future developments. Information about any future
developments affecting Form W-4 (such as legislation enacted
after we release it) will be posted at www.irs.gov/w4.
Personal Allowances Worksheet (Keep for your records.)
Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . .
A
• You are single and have only one job; or
• You are married, have only one job, and your spouse does not work; or
Enter “1” if:
. . .
B
• 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. But, you may choose to enter “-0-” if you are married and have either a working spouse or more
than one job. (Entering “-0-” may help you avoid having too little tax withheld.) . . . . . . . . . . . . . .
C
Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . .
D
Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above)
. .
E
Enter “1” if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit
. . .
F
(Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)
Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.
• If your total income will be less than $65,000 ($100,000 if married), enter “2” for each eligible child; then less “1” if you
have two to four eligible children or less “2” if you have five or more eligible children.
G
• If your total income will be between $65,000 and $84,000 ($100,000 and $119,000 if married), enter “1” for each eligible child . . .
Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.) ▶ H
A
{
B
C
D
E
F
G
H
For accuracy,
complete all
worksheets
that apply.
}
{
• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions
and Adjustments Worksheet on page 2.
• If you are single and have more than one job or are married and you and your spouse both work and the combined
earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to
avoid having too little tax 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.
Separate here and give Form W-4 to your employer. Keep the top part for your records.
Form
W-4
Department of the Treasury
Internal Revenue Service
1
Employee's Withholding Allowance Certificate
OMB No. 1545-0074
▶ Whether you are entitled to claim a certain number of allowances or exemption from withholding is
2015
subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
Your first name and middle initial
Last name
Home address (number and street or rural route)
2
3
Single
Married
Your social security number
Married, but withhold at higher Single rate.
Note. If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.
City or town, state, and ZIP code
4 If your last name differs from that shown on your social security card,
check here. You must call 1-800-772-1213 for a replacement card. ▶
5
6
7
Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2)
5
Additional amount, if any, you want withheld from each paycheck
. . . . . . . . . . . . . .
6 $
I claim exemption from withholding for 2015, 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 because I expect to have no tax liability.
If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . ▶ 7
Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.
Employee’s signature
(This form is not valid unless you sign it.)
8
Date
▶
Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.)
9 Office code (optional)
Cat. No. 10220Q
10
▶
Employer identification number (EIN)
Form W-4 (2015)
Staffing, LLC
EMPLOYEE EXPECTATIONS
As an employee of AT Staffing, LLC, you will be expected to adhere to the following policies. Failure to do so could result in
immediate termination of employment. Please initial next to each statement and sign and date at the bottom.

Failure to report to an assignment without notifying AT Staffing, LLC in advance will result in immediate termination. You
WILL NOT be offered any future assignments.

It is ultimately your responsibility to turn in your time sheet, even if the client tells you that he will fax it. Hours must be
received by 9:00 am on Monday. We value you as an employee and want to ensure that you are paid in a timely manner.

Time sheets must be faxed or handed in at the end of each work week, All –Temps work weeks end on Sunday. AT Staffing,
LLC pays on a weekly payroll cycle, with funds deposited on Friday. The deadline for time sheet submittal is Monday at 9:00
am.

AT Staffing, LLC policy is to pay via Direct Deposit. Please print and complete a direct deposit form, with voided check or
stamped direct deposit information from your financial institution.

Direct Deposit receipts will be distributed ONLY to its recipient. AT Staffing DOES NOT give out cash advances.

The reason given for calling in for time off will be accepted at the discretion of AT Staffing, LLC. It may or may not be deemed
a reasonable excuse, and you will be advised immediately if you are expected to continue on assignment.

If you walk off of an assignment without giving prior notification to AT Staffing, LLC, any hours that you have not yet been
paid for, will automatically be paid at the current minimum wage rate.

All employees must provide their own work or steel-toe boots and be available by phone. Shorts are NOT permitted on any job
site.

All injuries must be reported immediately of occurrence.

Our policy includes random drug screens; refusal will result in immediate termination. Reporting to a job site under the
influence of drugs or alcohol will result in immediate termination.

It is clearly understood that, while on assignment, you are an employee of AT Staffing, LLC and NOT the company at which
you are assigned. Any employment issues must be brought to the attention of our office, IN ADDITION TO a supervisor at the
location that you are currently reporting to.

While on assignment, you are representing the quality of employees that we provide to our clients. You are expected to conduct
yourself accordingly. Any negative behavior that misrepresents AT Staffing, LLC will have consequences that may result in
termination.

You must notify our office within 24 hours of being released from an assignment.
I have read and understood all “Employee Expectations.” I agree to comply with the above policies while
employed with AT Staffing, LLC.
SIGNED___________________________________ DATE _________________
Staffing, LLC
Sexual Harassment Employee Acknowledgment
It is the policy of this Firm not to condone or permit any sexual harassment of our personnel. This would be in
violation of Title VII of the Civil Rights Act. Any person guilty of committing any of the following acts may be
discharged without notice. These acts include, but are not limited to unwelcome sexual advances, request for
sexual favors, or other verbal or physical conduct of a sexual nature that constitute unlawful sexual harassment
by:
1. Indicating submission to the conduct is either an explicit or implicit term or condition of employment;
2. Utilizing submission to or rejection of sexual advances as a basis for an employment decision affecting
the person rejecting or submitting to the conductor; or
3. If the conduct has the purpose or effect of substantially interfering with an affected person’s work or
performance or creating an intimidation, hostile or offensive work environment.
In the event that any of our employees feel that there is a violation of the type mentioned herein or any other
type of discriminatory conduct prohibited by Title VII of the Civil Rights Act or by any local, state or federal
anti discrimination ordinance, law or regulation, he or she should immediately bring it to the attention of your
immediate Supervisor and/ pr Ronald H. Park, Owner.
I ____________________ understand and agree to abide by the Sexual Harassment policy set forth by AT
Staffing, LLC.
________________________________
Employee’s Signature
______________________
Date
________________________________
Witness
_______________________
Date
Signed/dated copy will be retained in employee personnel file.
4639 Corona, Suite 99 • Corpus Christi, TX 78411
Office (361) 808-8367 • Fax (361) 808-8369
Staffing, LLC
Alcohol and Drug Abuse Policy
AT Staffing, LLC is a drug-free workplace. The purpose of this policy is to ensure the safety of all employees
and to promote productivity. This policy applies to all employees, contractors, and temporary workers.
Substances covered under this policy include alcohol, illegal drugs, inhalants, prescription, and over-the-counter
drugs.
We reserve the right to inspect our premises or these substances. We reserve the right to conduct alcohol and
drug test at anytime. We may terminate your employment if you violate this policy, refuse to be tested, or
provide false information.
Company Rules
You must follow these rules while you are on company premises and while you conduct company business. The
rules apply any place you conduct business, including a company vehicle or your own vehicle:
AT Staffing, LLC will not tolerate any use of illegal drugs, non prescribed drugs or alcohol during work hours.
If the employee comes to work under the influence of drugs or alcohol or uses drugs or alcohol during work
time, the employee will be immediately terminated.
PRE-EMPLOYMENT TESTING: any employee may need to submit to a pre-employment drug screen based on
the client request prior to start date. If the employee refuses to submit to the drug screen he or she will not be
allowed to work for that client and this will result in termination.
POST-ACCIDENT TESTING: any employee involved in an on-the-job accident or injury will be required to
submit to a drug test. “Involved in an on-the-job accident or injury” means not only the one who was injured,
but also any employee who potentially contribute to the accident or injury event in any way.
You must cooperate with any investigation into substance abuse. An investigation may include tests to detect
alcohol, drugs, or inhalants.
4639 Corona, Suite 99 • Corpus Christi, TX 78411
Office (361) 808-8367 • Fax (361) 808-8369
Testing
Testing may include urine, blood, swab, and breathalyzer tests. Before testing you will have the chance to
explain the use of any prescription drugs. We will follow all laws for keeping test results confidential.
If the employer receives notice that the employee’s test results were confirmed positive, the employee will be
responsible for all expenses associated with the injury. The employee will be given the opportunity to explain
the positive result following the employee’s receipt of the test result. AT Staffing, LLC and the client will not
be responsible for any liability associated with the injury.
An individual testing positive may not work or apply with AT Staffing, LLC for a time period of 90 days. At
the end of this period, the individual is responsible for any cost associated with testing for employment
considerations.
Agreement to follow policy
I have received and read a copy of the Safety Policy for AT Staffing, LLC. I agree to follow the rules in the
policy.
___________________________
Employee signature
_________________________
Date
___________________________
Witness signature
_________________________
Date
4639 Corona, Suite 99 • Corpus Christi, TX 78411
Office (361) 808-8367 • Fax (361) 808-8369
Staffing, LLC
EMPLOYEE TERMINATION NOTICE REQUIREMENT
I understand that Texas in an “Employment at Will” state and agree that my employment is for no definite period and may be
terminated at any time for any reason.
I understand that once a specific job assignment is completed or I am terminated, I am required to report back to my AT Staffing, LLC
representative within 72 hours for future employment assignments.
FAILURE TO COMPLY WITH THIS REQUIREMENT MAY CAUSE UNEMPLOYMENT BENEFITS TO BE DENIED.
_________________________________________
Employee’s signature
_________________________
Date
-------------------------- ------ ------ ----- ------- ----- ----- ---- ----- FOR OFFICE USE ONLY
Date of Termination:
____________________________________
Date Employee Reported for Reassignment:
____________________________________
_________________________________________
Signature of Employer
___________________________
Date
4639 Corona, Suite 99 • Corpus Christi, TX 78411
Office (361) 808-8367 • Fax (361) 808-8369
4639 Corona, Suite 99 • Corpus Christi, TX 78411
Office (361) 808-8367 • Fax (361) 808-8369