List below all present and past employment starting with your most recent employer (last five years is sufficient). Account for all periods of unemployment. You must complete this section even if attaching a resume.

List below three persons not related to you who have knowledge of your work performance within the last three years.

Discloser of Confidential Information: Jochen P. Pechak DDS MSD Inc, The Perio & Implant Center of the Monterey Bay & Silicon Valley

Dr. Jochen and Maya Pechak

For valuable consideration, I hereby confer on AAT Photo, LLC (doing business as Loft Light Media), and their legal representatives, licensees and assigns the absolute and irrevocable right and permission with respect to the photographs, video and any other media that it has taken of myself in which I may be included with others, composite or retouched in character or form:

1. The right to copyright the same in any name that it may select;
2. The right to use, re-use, publish and re-publish the same in whole or in part, separately or in conjunction with other photographs or video, in any medium now or hereafter known, and for any purpose whatsoever, including (but not by way of limitation) illustration, promotion, advertising or purposes of trade.

I also release any claims and demands I may have ensuing from or in connection with the use of or publication of any picture, video, portrait or other media in accordance with this release, including claims that such use or placation invades my privacy or violates my rights of confidentiality as a patient, customer or employee. I understand that I will not receive any payment or compensation of any kind.

Because these photographs, video or other media, in which I may be recognizable, were taken in the course of service delivery, treatment or work, I certify that I have no objection to their publication and that I know that I am waiving any rights I may have as a patient, customer or employee to refuse permission or prohibit their use or publication. I understand that this release may not be revoked.

I hereby certify that I am of legal age and am competent to contract on my own behalf. I have read this release before signing below, and I fully understand the contents, meaning, and impact of this release and do hereby give my consent without reservation to the foregoing:

I understand that the above Practice property has been loaned to me for my use while employed by the Practice.  It is not for personal use unless authorization has been granted in writing by management.

I agree that the Practice has the right to expect me to be responsible for the care and maintenance, as appropriate, of the above items.  I agree to report damage and needed repair as required.

I also understand that I am to return any and all items loaned to me upon request or upon termination of employment. 

To Enroll in Full service Direct Deposit, simply fill out this form and give to your payroll Manager. Attach a voided check for each checking account-not a deposit slip. If depositing to saving accounts, ask your bank to give you the Routing/Transit Number for your account. It isn't always the same as the number on the savings deposit slip. This will help ensure that you are paid correctly.

Below is the same check MICR Line, detailing where the information necessary to complete this form can be found.

I hereby authorize ADP to deposit any amounts owed me, as instructed by my employer, by initiating credit entries to my account at the financial institution (hereinafter “Bank”) indicated on this form. Further, I authorize Bank to accept and to credit any credit entries indicated by ADP to my account. In the even that ADP deposits funds erroneously into my account. I authorize the ADP to debit my account for an amount not to exceed the original amount of the erroneous credit.

                This authorization is to remain in full force and effect until ADP and Bank have received written notice from me of its termination in such time and in such manner as to afford ADP and Bank reasonable opportunity to act on it.

Make sure to indicate what kind of account, along with the amount to be deposited, if less than your total net payback

ATTENTION PAYROLL MANAGER:

Employers must keep each original employee enrollment form on the file as long as the employee is using FSDD, and for two years thereafter.

ADP is a registered trademark of ADP of North America Inc.
Full Service Direct Deposit (FSDD) is a services mark of Automatic Data Processing, Inc.
02-184-049 10M Printed in USA ©1999, 1998 Automatic Data Processing, Inc.

I hereby understand, 10 minute rest breaks and meal breaks must be taken as a protocol of this office, If I choose not to take my break, I must voluntarily waive meal & breaks as follows:

First Meal Break

I understand that if I work for a period of more than five (5) hours in a day, I am entitled to an unpaid meal break of not less than 35 minutes, a required 1 hour is our protocol.

I also understand that if I work a total of no more than six (6) hours in a day, I may voluntarily waive my meal break to depart early, for a single date or for recurring dates by mutual consent of both myself and Perio & Implant Center of Silicon Valley & Monterey. To do this, I must consent to submitting this form, see below.

Second Meal Break

I understand that if I work for a period of more than 10 hours in a day, and that all overtime must be authorized by a signed form, authorized and signed by my owners, at any time beyond 9.25 hours, I am entitled to a first unpaid meal break of not less than 35 minutes and a second unpaid meal break of not less than 35 minute.

I also understand that if I work a total of no more than 12 hours in a day, I may voluntarily waive my second meal break for a single date or for recurring dates by mutual consent of both myself and Perio & Implant Center of Silicon Valley & Monterey, but only if my first meal break was not waived.

I acknowledge that Perio & Implant Center of Silicon Valley & Monterey does not encourage, discourage or solicit the waiver of meal periods, and that I enter into this agreement freely and voluntarily. I also understand that my consent to waive the above meal breaks can be revoked in writing by either me or Perio & Implant Center of Silicon Valley & Monterey at any time.

If you are not willing to agree to this, please let us know by completing the below.
Revocation of Meal Break Waiver
I hereby revoke the above meal break waiver.