PLEASE READ BEFORE FILLING OUT!!
Thank you for your interest in Staffing Support Solutions. Please fill
out these forms 100%. You can complete them on your computer,
phone, or tablet. We have highlighted sections where your
information needs to be filled in. At the end of the application packet,
you will choose which state tax forms you will be filling out. In each
attachment, an I9 and W4 form is included. These tax forms must
be printed, filled out and faxed/emailed separately. You can find
our fax number and email information on our website. When you
send us the tax forms, please be sure to send copies of either your
ID and Social Security card OR Current Passport (expired
IDs/Passports are prohibited). If you are unsure if the IDs you have
will suffice, please call Josh Bean 919-605-4586.
If you do not know your Routing and/or Account Number for Direct
Deposit, please call Josh and let him know. If you do not supply us
with this information before your first paycheck, we will mail you a
Global Cash Card and this is how you will be paid moving forward. If
you wish to receive a Global Cash Card for your weekly paychecks,
please fill out the bottom part of the Direct Deposit form stating that
is what you would like.
This application will only be deemed complete when everything is
filled out correctly and IDs have been sent.
FIELD EMPLOYEE NEW-HIRE CHECKLIST
Employee Name:
__________ Date:
______
Employee SS#:________________________ Employee date of birth: ________________________
Phone #:_____________________________ Email:_______________________________________
Job Title:___________________________________
Internal Office Only:
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Application
ROI
Direct Deposit/Cash Card
Self-Identification
Post-Offer Medical
PPE $______
Policy Acknowledgment
NC-4
W-4
I-9
IDs
S3 Rep Initials __________
 Page 2
Pay Rate: ___________________________
EMPLOYMENT APPLICATION
FILL OUT EVERY SECTION OF THIS APPLICATION
APPLICANT INFORMATION
Last Name
First
M.I.
Street Address
Date
Apartment/Unit #
City
State
Phone
E-mail Address
Date of Birth
ZIP
Social sec. number
Position Applied for
Have you ever worked for this company?
YES
NO
Are you legally authorized to work in the U.S on
YES
a full time basis?
Have you ever been convicted of a crime?
YES
NO
If yes, explain?
Have you ever been convicted of a felony? And/ or
any felony charges pending against you?
YES
NO
If yes, explain
EDUCATION
High School
From
Address
To
Did you graduate?
College
From
YES
NO
Degree
NO
Degree
NO
Degree
Address
To
Did you graduate?
Other
YES
Address
From
To
Did you graduate?
YES
REFERENCES
Please list three professional references.
Full Name
Relationship
Company/Address
Phone
Full Name
Relationship
Company/Address
Phone
Full Name
Relationship
Company/Address
Phone
 Page 3
(
(
(
)
)
)
NO
PREVIOUS EMPLOYMENT
Company
Phone
Address
Supervisor
Job Title
Starting Salary
(
)
$
Ending Salary
$
Ending Salary
$
Ending Salary
$
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference?
YES
NO
Company
Phone
Address
Supervisor
Job Title
Starting Salary
(
)
$
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference?
YES
NO
Company
Phone
Address
Supervisor
Job Title
Starting Salary
(
)
$
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference?
YES
NO
MILITARY SERVICE
Branch
From
Rank at Discharge
Type of Discharge
Service Status
Veteran _____ Vietnam Era Veteran _____
If other than honorable, explain
 Page 4
Newly Separated Veteran _____
To
DISCLAIMER AND SIGNATURE
ferences and Background Checks, I understand that my employment may be based on receipt of satisfactory results of a background check, including criminal
history, credit history, and Social Security number verification, if deemed appropriate. I authorize Staffing Support Solutions, LLC and its representatives to
investigate, without liability, any information supplied by me. I also authorize listed employers, school and references, as well as other reference sources, to
make full disclosure to any relevant inquiries by Staffing Support Solutions, LLC and its representatives without liability. In event that Staffing Support
Solutions, LLC is unable to verify any reference stated on this application, it is my responsibility to furnish the necessary documentation.
Minimum Age Compliance - If I am under the minimum working age, I agree to furnish a work permit prior to hire.
Immigration Reform and Control Act of 1986 Compliance - I understand that in compliance with the Immigration Reform Act of 1986, I will be expected to
produce the required documentation to establish my identity and eligibility to work. Employment at Staffing Support Solutions, LLC is contingent upon my
producing the required documentation or evidence of having applied for it with in three calendar days after hire.
Drug Testing - Except as limited by law, I accept that Staffing Support Solutions, LLC may test applicants and employees prior to or during employment for the
use of illegal drugs and controlled substance.
Confidentiality - If hired, I agree to be discrete when discussing any financial, proprietary, trade or other confidential information related to Staffing Support
Solutions, LLC, business activities. I understand that revealing such information is ground for immediate termination.
EEO Statement - Staffing Support Solutions, LLC is an equal opportunity employer and abides by all federal, state, and local laws prohibiting discrimination in
employment based on race, color, religion, sex, national origin, age, disability, veteran status, and all other protected groups.
At-Will Statement – Employment at Staffing Support Solutions, LLC is on an “at-will” basis and is for no definite period and may, regardless of the date or
method of payment of wages or salary, be terminated at any time with or without cause and with or without notice.
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false
or misleading information in my application or interview may result in my release.
Signature
 Page 5
Date
S3 AUTHORIZATION TO RELEASE INFORMATION
Employee Name
Date of Birth __________________________
Social Security Number _______________________________________________________________
I authorize Staffing Support Solutions, LLC to release information to:
Business Name: ____Sterling National Bank___________________________
Street Address: ____310 Crossways Park Dr.____________________________
City/State/Zip Code: ____Woodbury, NY 11797_________________________
Phone Number: ____516-682-1458__________________________________
 Any client that I am placed with may require this information as well. I agree that my information
may be released to any client that I am placed with.
YES
NO
I authorize the release of my Criminal Background results, whether negative
or positive, to the business/person(s) listed above. I understand that the business/person(s) listed above will be
notified that I must give specific written permission before disclosure of these results to anyone.
YES
NO
I authorize the release of my drug and alcohol results, whether negative or
x
x
positive, to the business/person(s) listed above. I understand that the business/person(s) listed above will be
x
notified that I must give specific written permission before disclosure of these results to anyone.
Name (Printed) _____________________________________________
Signature ________________________________
 Page 6
_
Date ________________
DIRECT DEPOSIT AGREEMENT FORM
Authorization Agreement
I hereby authorize Staffing Support Solutions, LLC to initiate automatic deposits to my account at the financial
institution named below. I also authorize Staffing Support Solutions, LLC to make withdrawals from this
account in the event that a credit entry is made in error.
Further, I agree not to hold Staffing Support Solutions, LLC responsible for any delay or loss of funds due to
incorrect or incomplete information supplied by me or by my financial institution or due to an error on the part of
my financial institution in depositing funds to my account.
This agreement will remain in effect until Staffing Support Solutions, LLC receives a written notice of
cancellation from me or my financial institution, or until I submit a new direct deposit form to the Payroll
Department.
Personal Account Information
Name of Financial Institution:
Routing Number:
Checking
Savings
Account Number:
Signature
Employee Signature :
Date:
Employee Name (Print):
SS#
Please attach a voided check or deposit slip and return this form to the Payroll Department.
OR
Global Cash Card Information
(only fill this below section out to receive a cash card)
Employee Name: __________________________________________________
Employee Date of Birth: ____________________________________
Employee social security #:_________________________________
Global Cash Card #:_________ -__________-__________-___________
 Page 7
EEO Self Identification Form
Our company, Staffing Support Solutions, LLC, is subject to certain governmental record-keeping and reporting
requirements for the administration of civil rights laws and regulations. In order to comply with these laws, Staffing
Support Solutions, LLC invites you to voluntarily self-identify your race or ethnicity by checking the appropriate box
below.
Race and ethnic designations as used by Equal Employment Opportunity Commission and on this self-identification
form do not denote scientific definitions of anthropological origins.
Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment.
The information obtained will be kept confidential and may be used only in accordance with provisions of applicable
laws, executive orders, and regulations, including those that require the information to be summarized and reported
to the federal government for civil rights enforcement. When reported, data will not identify any specific individual.
PLEASE CHECK THE APPROPRIATE BOX:
Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish
culture or origin regardless of race.
White, (Not Hispanic or Latino) - A person having origins any of the original peoples of Europe, the Middle
East, or North Africa.
Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups
of Africa.
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the
peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Asian (Not Hispanic or Latino)- A person having origins in any of the original peoples of the Far East,
Southeast Asia, or the Indian Subcontinent, including for example, Cambodia, China, India, Japan, Korean,
Malaysia, Pakistan, the Philippine Island, Thailand, and Vietnam.
American Indian or Alaska Native (Not Hispanic or Latino) - A person having origins in any of the original
peoples of North and South America (including Central America), and who maintains tribal affiliation or
community attachment.
Two or More Races (Not Hispanic or Latino) - All persons who identify with more than one of the above five
races.
Male
Female
Name (Printed) ____________________________
Signature ________________________________
 Page 8
Date ________________
Post-Offer Medical Questionnaire
Name: _________________________
SSN#: ____________________
ANSWER EVERY QUESTION
Notice: In compliance with the Americans with Disabilities Act of 1990 (ADA) you have received a
conditional offer of employment. This medical history statement is required. The answers to the
medical history statement and any medical examination will be kept confidential as required by the
ADA and HIPPA. The job offer, which you have received, is conditioned upon satisfactory completion
and review of this medical history statement; any required medical examination or follow up and job
assignment availability.
Employee Affirmation: I herewith affirm that the employer has made me an offer of employment.
The purpose of this inquiry is to determine whether I currently have the physical qualifications
necessary to perform the job that has been offered; to determine whether and what accommodations
may be necessary; and to determine whether I can perform the job without posing a significant/direct
threat to the health and safety of myself or others. This information will be kept confidential in a
separate medical file, apart from my personnel file. I hereby affirm that the questions in the medical
questionnaire have not been asked of me by anyone with the employer until after I have signed this
statement and been offered a conditional job.
1.
2.
Have you ever had or been treated for any of the following conditions or disease?
YES NO
Herniated disc
____ ____
Knee injury
Surgical removal of disc or spinal fusion
____ ____
Back injury
Diseased process of the spine
____ ____
Neck injury
Chest pain
____ ____
Shoulder injury
Arthritis or rheumatism
____ ____
Arm/hand injury
YES
___
___
___
___
___
NO
____
____
____
____
____
If you answered “yes” to any of the above, please explain.
3. Please list any conditions or diseases) including ones not listed above) for which you have been treated in
the past three Years. If no treatment has been provided, state “none.
4. Have you ever been hospitalized? If so, for what condition? If you have not been hospitalized,
state “none”.
5.
Have you had a major illness in the past five years? If none, state “none”.
6.
How many days were you absent from work in the past year? If none, state “none”.
 Page 9
7. Do you have any physical or mental difficulties that could interfere with the performance of your
duties?
____ YES
____ NO
8. Do you have AIDS/HIV or any communicable diseases? (Do not identify AIDS/HIV unless your
position involves medical care or other risk of blood transmission). If yes, please explain.
9. Has a doctor given you an impairment rating? If so, please provide the reason and the
percentage of impairment. If not, state “none”.
10. Have you ever had an injury, operation or any disability not covered by the above question? If
yes, please explain. If not, state “none”.
11. Are you taking any prescribed drugs that would interfere with your job performance? If yes,
please list medications. If not, state “none”.
12. How much weight can you lift comfortably?
Less than 15 lbs. __
15-25 lbs. __
___________________________
Signature
 Page 10
25-50 lbs. __
over 50 lbs. __
over 100 lbs. __
___________________________
Date
PPE Issued
I, _____________________________________, choose to accept the following PPE from Staffing
Support Solutions, LLC. I understand and agree that the charges for this PPE will be deducted from
my first payroll check.
Initials:
_______
Clear Safety Glasses ($2.50)
_______
Work Gloves ($2.50)
_______
Hard Hat ($10.00)
_______
Safety Vest/Neon Safety Shirt ($10.00)
_______
Total: $________
Employee Printed Name _______________________________________
Employee Signature ___________________________________________
Social Security Number ____________________________
Date _________________
 Page 11
POLICIES AND PROCEDURES
I have been explained S3’s policies and procedures, which I have read and understand. I
understand and agree that S3’s policies and procedures may be changed from time to time at S3’s
discretion, without advance notice. I understand that I am expected to adhere to the policies and
procedures and be subject to the discipline set forth in them.
I understand that the policies and procedures do not provide any contractual right or guarantees of
employment and that my employment is for no duration. I further understand that my employment
relationship may be terminated at any time with or without cause, either by myself or S3, and this
understanding cannot be modified except by written agreement signed by the President of S3.
Employee Name Printed ________________________________________
Employee Signature ________________________________________
Date ____________________
DOUBLE-CLICK THE APPROPRIATE STATE OF RESIDENCE, FILL THEM OUT, AND FAX
WITH THIS HIRE PACKET. THESE PDF FILES BELOW ARE ACTUAL FILES, MAKE SURE TO
OPEN THEM, DO NOT UNDERLINE OR CIRCLE THEM!!!!
North Carolina Tax
Forms.pdf
 Page 12
South Carolina Tax Forms.pdf
Virginia Tax Forms.pdf