BRABEN INTERIORS EMPLOYMENT APPLICATION

EMPLOYMENT APPLICATION
BRABEN INTERIORS
PERSONAL INFORMATION
Full Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MOBILE:*
Social Security Number*
Email Address
example@example.com
Are you a citizen of the U.S. or do you have legal right to work in the U.S.?*

YESNO
Are you 18 years of age or older?*

YESNO
Have you ever pleaded “guilty”, “no contest” or been convicted of a crime?*

YESNO
If “Yes”, please provide details:
Date available to start:*

MonthDayYear
Date
Position applying for*
Do you have a valid Drivers License?*

YESNO
Do you have a valid CDL Drivers License*

YESNO
CERTIFICATION & ACKNOWLEDGMENT
I certify that the information provided herein is true and correct to the best of my knowledge. I understand that, if employed, falsified statements on this Application for Employment form will be considered grounds for termination.

I also authorize the following agencies and entities to disclose to the Background Check Company and its agents all information about or concerning me, including but not limited to: my past or present employers; learning institutions, including colleges and universities; law enforcement and all other federal, state and local agencies; federal, state and local courts; the military; credit bureaus; testing facilities; motor vehicle records agencies; if applicable, worker’s compensation injuries; all other private and public sector repositories of information; and any other person, organization, or agency with any information about or concerning me. Workers’ compensation information will only be requested in compliance with federal Americans with Disabilities Act and/or any other applicable federal, state or local laws and only after a conditional job offer is made. The information that can be disclosed to the Background Check Company and its agents includes, but is not limited to, information concerning my employment history, earnings history, education, credit history, motor vehicle history, criminal history, military service, professional credentials and licenses and substance abuse testing.

I agree the Company may rely on this authorization to order background reports, including investigative consumer reports, from companies other than the Background Check Company without asking me for my authorization again as allowed by law. I also agree that a copy of this form is valid like the signed original. I certify that all of the personal information I provided is true and correct.
Signature*

Clear
Date*

MonthDayYear
Date
BRABEN INTERIORS
Full Name*
I , understand I will have to reimburse BRABEN INTERIORS

the cost and fees associated with any failed drug test given to me as well as any lost/stolen or misplaced badges on any of the FLL airport jobs.

Lost/Stolen or misplaced Turner Badge $100.00

Fail to provide correct TSA documents $60.00

AIRPORT BADGES CAN INCUR TWO (2) FINES
- Not reporting Lost, Stolen or Expiration badge - $1000.00
- Not returning Lost, Stolen or Expiration badge - $1000.00
I agree for BRABEN INTERIORS to deduct fees for reimbursement out of my weekly paycheck
Full Name*
Employee Signature*

Clear
Date*

MonthDayYear
Date
Date

MonthDayYear
Date
POST-HIRE
MEDICAL QUESTIONNAIRE
(To be completed after an offer of employment is extended)
NAME OF EMPLOYER*
Full Name*
Social Security Number*
HEIGHT*

FeetInches
WEIGHT*

1. Do you have or have you ever had any of the following? (please answer all)*

	YES	NO
Epilepsy (convulsions, seizures)
Diabetes
Cardiac (heart) disease
Meniscetomy (inflammation of cartilage of certain joints (eg. knee)
Amputation of foot, leg, arm or hand
Total loss of sight of one or both eyes, or partial loss of corrected vision of more than 75% bilateral
Cerebral palsy
Multiple sclerosis
Parkinson’s disease
Patelectomy (surgically remove the kneecap)
Ruptured cruciate ligament (knee ligament)
Hemophilia
Chronic osteomyelitis (infection in the bone)
Surgical or spontaneous fusion of a major weight-bearing joint (frozen joint)
Hyperinsulinism
Muscular dystrophy
Thrombophlebitis
Herniated inter vertebral disk or spinal fusion
Total deafness
One or more back or neck injuries or a disease process of the back or neck sustained by a doctor’s opinion and resulting in disability over a total of 120 or more days
Obesity (30% overweight)

Other
2. Have you previously received worker’s compensation for an on-the-job injury*
If yes please write why, when and where
3. Have you ever received a disability rating or had one assigned to you by an insurance company or stale/federal agency?*
4. Have you ever injured or sprained your back?*
If yes did you have surgery?
If yes please give details
5. Have you every injured or sprained your neck?*
If yes did you have surgery?
If yes please give details
6. Have you ever injured or sprained a knee?*
If yes did you have surgery?
If yes please give details
7. Have you ever had any other type of surgery not mentioned above?*
If yes please give details
8. Do you have arthritis?*
Are you on any medication for arthritis?
If yes, what parts are affected
Date*

MonthDayYear
Date
Signature*

Clear
NOTICE THIS IS A DRUG-FREE WORKPLACE
Hourly Rate:
Job Location:
Start Date:

MonthDayYear
Date
Full Name*
DATE OF BIRTH*

MonthDayYear
Date
MOBILE:*
TRADE:*
SKILL LEVEL*
REFERRED BY:*
PERSON TO NOTIFY IN CASE OF AN EMERGENCY
NAME:*
RELATIONSHIP:*
MOBILE:*
CERTIFICATION
Date*

MonthDayYear
Date
(DATE- FECHA DE HOY), I received a copy of BRABEN

INTERIORS Safety policy, a copy of BRABEN INTERIORS Field Employee Policy & Procedure Manual, Drug Free Workplace Handbook, a hard hat and a pair of safety glasses. I have read these policies and fully understand their contents. We are a drug free company. Employees/ Applications who take and fails any drug test given by BRABEN INTERIORS, will have to reimburse the cost and fees associated with the test. Employees will also have to reimburse the cost of drug test if employee has worked less than 14 days once the test is given. I also certify that I will immediately (within five (5) minutes) report to my Foreman any and all injuries, cuts, abrasions, strains, etc., I incur or that I see or hear of occurring. If an event did occur, a drug test may be given with in 24 hours of an accident. If passed, BRABEN INTERIORS will accommodate employee with light duty work.
Signature*

Clear
Date*

MonthDayYear
Date
Employment Eligibility Verification

USCIS
Department of Homeland Security

For I-9
Form I-9
►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.
Last Name (Family Name)*
Name*

First Name (Given Name)Middle InitialOther Last Names Used (if any)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth (mm/dd/yyyy)*

MonthDayYear
Date
U.S. Social Security Number (First set of digits 123-xx-xxxx)*
U.S. Social Security Number (Second set of digits xxx-45-xxxx)*
U.S. Social Security Number (Last set of digits xxx-xx-6789)*
Employee's E-mail Address
youremail@example.com
Employee's Telephone Number
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 of this form. I attest, under penalty of perjury, that I am (check one of the following boxes):
I attest, under penalty of perjury that I am (Check one of the following boxes)*

1. A citizen of the United States2. A noncitizen national of the United States (See instructions)3. A lawful permanent resident4. An alien authorized to work until,
(Alien Registration Number/USCIS Number):
(expiration date, if applicable, mm/dd/yyyy):

MonthDayYear
Date
1. Alien Registration Number/USCIS Number:
2. Form I-94 Admission Number:
3. Foreign Passport Number:
Country of Issuance:
Signature*

Clear
Date*

MonthDayYear
Date
Preparer and/or Translator Certification (check one):*

I did not use a preparer or translator.A preparer(s) and/or translator(s) assisted the employee in completing Section 1.
(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.
Preparers / Translator Signature

Clear
Date

MonthDayYear
Date
Preparer / Translator Name

First Name (Given Name)Last Name (Family Name)
Preparer / Translator Address

Address (Street Number and Name)

Street Address Line 2

City or TownState

ZIP Code
Employment Eligibility Verification

USCIS
Department of Homeland Security

Form I-9
U.S. Citizenship and Immigration Services

OMB No. 1615-0047 Expires 10/31/2022

Section 2. Employer or Authorized Representative Review and Verification

(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")
Employee Info from Section 1
Name*

First Name (Given Name)Middle InitialLast Name (Family Name)
Citizenship/Immigration Status*
The employee's first day of employment (mm/dd/yyyy):

MonthDayYear
Date
(See instructions for exemptions)
Signature of Employer or Authorized Representative
Date*

MonthDayYear
Date
Title of Employer or Authorized Representative
Name

Employer's Business or Organization NameLast Name of Employer or Authorized Representative
First Name of Employer or Authorized Representative
Address

Employer's Business or Organization Address (Street Number and Name)

Street Address Line 2

City or TownState

ZIP Code
Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative

B. Date of Rehire (if applicable)
First Name (Given Name)
First Name (Given Name)
Middle Initial
Date*

MonthDayYear
Date
C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.
Document Title
Document Number
Expiration Date (if any) (mm/dd/yyyy)

MonthDayYear
Date
I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.
Signature of Employer or Authorized Representative
Date*

MonthDayYear
Date
Name of Employer or Authorized Representative
Employee’s Withholding Certificate 2020

Department of the Treasury Internal Revenue Service
Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Give Form W-4 to your employer. Your withholding is subject to review by the IRS.
Step 1:

Enter Personal Information
Name*

First Name (Given Name)Middle InitialLast Name (Family Name)
Social Security Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does your name match the name on your social security card? If not, to ensure you get credit for your earnings, contact SSA at 800-772-1213 or go to www.ssa.gov.
(c) Select one*

Single or Married filing separatelyMarried filing jointly or Qualifying widowerHead of household Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual
Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can claim exemption from withholding, when to use the online estimator, and privacy.
Step 2:

Multiple Jobs or Spouse Works
Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse also works. The correct amount of withholding depends on income earned from all of these jobs. Do only one of the following. (a)Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3–4); or (b)Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding; or If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option (c)

is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld .
TIP: To be accurate, submit a 2020 Form W-4 for all other jobs. If you (or your spouse) have self-employment income, including as an independent contractor, use the estimator.

Complete Steps 3–4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3–4(b) on the Form W-4 for the highest paying job
Step 3:

Claim Dependents
If your income will be $200,000 or less ($400,000 or less if married filing jointly):
Multiply the number of qualifying children under age 17 by $2,000
Multiply the number of other dependents by $500
Add the amounts above and enter the total here
Step 4:

(optional): Other Adjustments
4(a) Other income (not from jobs). If you want tax withheld for other income you expectthis year that won’t have withholding, enter the amount of other income here. This mayinclude interest, dividends, and retirement income
4(b) Deductions. If you expect to claim deductions other than the standard deductionand want to reduce your withholding, use the Deductions Worksheet on page 3 andenter the result here
4(c) Extra withholding. Enter any additional tax you want withheld each pay period
Step 5: Sign

Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.
Employee’s signature This form is not valid unless you sign it*

Clear
Date*

MonthDayYear
Date
Employers

(Office Use Only)
Employer’s name and address
BRABEN INTERIORS LLC 4000 HOLLYWOOD BLVD SUITE 555-S HOLLYWOOD FL 33021
First date of employment

MonthDayYear
Date
Employer identification number (EIN)
For Privacy Act and Paperwork Reduction Act Notice, see page 3.
EMPLOYMENT ACKNOWLEDGMENT AGREEMENT
I hereby acknowledge that I have received this company’s Drug Free Workplace Handbook, which includes the company Drug Free Workplace policy, employee assistance information, a listing of drugs being tested for, common over-the- counter medications which may alter a drug test and educational material on substance abuse. I have also been given the opportunity to voluntarily complete a Medication Disclosure Form.

I freely and voluntarily agree and realize that as part of my employment, I may be subjected to future drug and/or alcohol screens for post-accident, reasonable suspicion, routine fitness-for-duty, return to work, follow-up, and/or random testing at the company’s discretion. l understand that a refusal to submit to a blood, urinalysis, hair and/or breath test will result in immediate termination from employment. l understand that a tampered or an adulterated drug and/or alcohol specimen will be considered a refusal to test, resulting in immediate termination. I understand that a confirmed positive drug and/or alcohol test will result in immediate termination of employment, but if I am able to successfully complete substance abuse treatment at my expense, and if a job is still available, I may be given one (1) chance to be rehired, upon a negative return to work drug and/or alcohol test. I understand that l will be subject to the company rehabilitation agreement and I will undergo random follow-up drug and/or alcohol tests for a period of two (2) years. I understand that a confirmed positive drug and/or alcohol follow-up test or any violation of the rehabilitation agreement will result in termination of employment.

I agree to voluntarily submit to a blood, urinalysis, hair and/or breath test for drug or alcohol use as part of my ongoing employment, and I release my employer from any liability resulting from my participation in such a screening. I understand that if I am injured during the course and scope of my employment and I test positive for the presence of alcohol and/or drugs, I may forfeit my eligibility for medical and indemnity benefits under Florida’s workers’ compensation law (Florida Statutes 440.101, 440.102 I also understand that a refusal to test under this circumstance will automatically result in forfeiture of my eligibility for medical and indemnity benefits and immediate termination from employment. I understand that a confirmed positive drug and/or alcohol test, a tampered with or an adulterated specimen or a refusal to test may result in forfeiture of unemployment benefits under Florida law.

I hereby give my consent to release the results of my blood urinalysis, hair and/or breath test to the person(s) or department(s) or the specified agent of my employer, including my employer’s Workers’ Compensation Insurance Company, for the purpose of determining the presence of alcohol and/or other drugs in my body for the duration of my employment. By signing this form, I hereby release to the Company and/or Company’s Medical Review Officer the results of the test(s) to which I have consented. I further authorize the Company to discuss the results with medical personnel/ physician collecting the specimen, the testing facility, its directors, officers, agents, and employees responsible for administrating the aforementioned test(s) or evaluating the results thereof and any of them herein. I also authorize the Company to discuss the results with its legal advisors and to use the test results as a defense to any legal action to which l am a party. I further release any testing facility or any physicians who have tested me from any liability arising from a release of any and all results, written reports, medical records, and data concerning my test(s) to the appropriate Employer officials. I agree to have the results released· to the Company and/or the Company’s Medical Review Officer.

l also understand that the Drug-Free Workplace policy and related documents are not intended to constitute a contract between this employer and myself.

As an employee, I understand and agree to abide by this company’s Drug-Free Workplace policy, under Florida statute 440.101 and 440.102, and have received a written 60-day notification of this program, if applicable.
Signature*

Clear
Full Name*
Date*

MonthDayYear
Date
As a job applicant, I freely and voluntarily agree to a hair or urinalysis drug screen as part of my application for

employment and I understand that a refusal to test, a positive confirmed drug test or a tampered with or an adulterated specimen will disqualify me from employment, even if I have started work pending the results of the drug test. l understand I am still completing the application process and will not officially be an employee until the company receives a negative preemployment drug test result. If l am employed by this company, I understand and agree to abide by this company’s Drug Free Workplace policy, under Florida statute 440.101 and 440.102, as stated above.
Signature

Clear
Full Name
Date

MonthDayYear
Date
NOTICE

THIS IS A DRUG-FREE WORKPLACE
BRABEN INTERIORS
This company is in agreement with the Federal Government that marijuana is an illegal controlled substance and will not recognize medical marijuana as a legitimate prescription. A positive test result for marijuana will be treated the same as any other positive test result, even if an applicant has a medical marijuana prescription. A negative preemployment drug test result is condition of employment with this company. Therefore, an applicant will be denied employment with this company if they test positive for marijuana even if they have a medical marijuana prescription.

Esta compañía está de acuerdo con el gobierno federal en que la marihuana es una sustancia ilegal controlada y no reconocerá la marihuana medicinal como una receta legítima. Un resultado positivo de la prueba de marihuana será tratado de la misma manera que cualquier otro resultado positivo de la prueba, incluso si el solicitante tiene una prescripción médica de marihuana. Un resultado negativo de la prueba de drogas anterior al empleo es la condición de empleo en esta compañía. Por lo tanto, a un solicitante se le negará el empleo con esta compañía si da positivo par marihuana, incluso si tiene una prescripción médica de marihuana.

Print Name: Imprimir el nombre
Full Name*
Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

EMPLOYMENT APPLICATION

BRABEN INTERIORS

PERSONAL INFORMATION

CERTIFICATION & ACKNOWLEDGMENT

BRABEN INTERIORS

POST-HIRE

MEDICAL QUESTIONNAIRE

NOTICE THIS IS A DRUG-FREE WORKPLACE

PERSON TO NOTIFY IN CASE OF AN EMERGENCY

CERTIFICATION

Employment Eligibility Verification

Department of Homeland Security

Form I-9

Employment Eligibility Verification

Department of Homeland Security

Employee Info from Section 1

Employee’s Withholding Certificate 2020

Step 1:

Step 2:

Step 3:

Step 4:

Step 5: Sign

Employers

EMPLOYMENT ACKNOWLEDGMENT AGREEMENT

NOTICE

BRABEN INTERIORS