Work History/Historial de Trabajo

(please list the most recent job/por favor anote el empleo mas reciente)

Month/Mes Year/Ano to/a Month/Mes Year/Ano

Month/Mes Year/Ano to/a Month/Mes Year/Ano

following are physical requirements pertaining to the job(s} for which you are applying. These recognized, bonafide physical requirements an ESSENTIAL FUNCTIONS of the job and are in addition to the skills, certification, years of experience or other qualifications required to perform he job(s) for which you have applied. This information will be used to determine appropriate job placement. It shall not be used to disqualify an otherwise qualified person. During an 8-hour shift. can you perform the following essential job functions with or without a reasonable accommodation?

 

GENERAL REQUIREMENTS

 

1. Lift and/or carry up to 40 pounds "periodically" during your shift. YES NO

2. Move about on foot as required. YES NO

3. Extend your hands and arms away from your body and move them in all directions. YES NO

4. Understand written and verbal instructions, to include safety information. YES NO

5. Read instructions, match numbers or letters, and identify colors. YES NO

6. Perform the same motion over and over again, such as continuous typing at a computer keyboard, especially YES NO movement of your wrists. hands, and/or fingers. YES NO

7. Wear proper safety equipment (including, gloves, aprons, safety glasses/goggles, hard hats) In areas where such YES NO safety equipment is required. YES NO

8. Wear dust masks in work areas where such safety equipment is required. such as infrequent visits to industrial YES NO work sites. YES NO

9. Work effectively around moving mechanical parts and electric wires. YES NO

10. Move objects up and down, and back and forth. YES NO

11. Pick. pinch, type. or otherwise work, mainly with your fingers rathe r than with your whole hand or arm. YES NO

12. Apply pressure to an object with your fingers and palm. YES NO

13. Keep your balance to prevent railing when walking. standing. crouching or going up or down stairs with your hands and arms on railing. YES NO

14. Bend your body downward and forward by bending at the waist (stooping). YES NO

15. Bend your legs at the knee to come to a rest on your knee or knees (kneeling). YES NO

16. Bend at the waist routinely. YES NO

17. Stand/sit for long periods of the day, if necessary. YES NO

18. Work effectively and perform job tasks in a sometimes noisy environment. YES NO

19. Do you have any condition that would have an effect on your ability to perform the duties of this position with or without reasonable accommodations? YES NO

20. Do you have any back limitations that would prevent you from perform typical warehouse duties? YES NO

21. Do you have any wrist limitations, including repetitive motion? YES NO

22. Have you ever had an injury to your hands/wrists/arms? YES NO

23. Have you ever had an injury to your back/neck/shoulders? YES NO

24. Have you ever had an injury to your legs/ankles/feet? YES NO

25. If you answered "yes" to question #22. #23. or #24. did the injury/injuries require surgery? YES NO

26. Do you have ANY health problems, or are you taking ANY medication that could affect your ability to perform normal job functions? YES NO

27. Do you have ANY allergies that would restrict you from working in certain environments or performing certain job functions? YES NO IF YOU ANSWERED YES TO (#19-27) PLEASE EXPLAIN BELOW: Name

siguiente son requisitos que pertenecen al trabajo(s) para cual usted esta aplicando. Estos requisitos fisicos autenticos son FUNCIONES ESENCIALES

del trabajo y son ademas se las habilidades, anos de experencia y otras calificaciones

Requisitos Generales

1. Puede levantar y/o llevar "periodicamente" 25 Iibras durante su turno SI NO

2. Puede moverse a pie alrededor como es requerido SI NO

3. Puede extender sus manos y brazos y moverlos en todas las dirocciones SI NO

4.Puede entender instrucciones por escrito y verbales incluyendo informacio sobre Ia seguridad SI NO

5. Puede leer instrucciones, numeros para emparejar, o letras y identificar colores SI NO

6. Puede desempenar el misomo movimiento continua una y otra vez obre todo elmovimiento de sus munecas, manos y/o dedos SI NO

7. Puede usar el equipo de seguridad apropiado (incluyendo: guantes, mantiles, gafas de seguridad, cascos de proteccion) SI NO

en areas donde taI equipo de segundad es requerido SI NO

8. Puede usar mascarias en areas de trabajo donde tal equipo se requiere SI NO

9. Puede trabajar eficazmento alrededor de las partes mecanicas moviles y los alambres electricos SI NO

10. Puede mover objetos de arriba abajo, y de un lado a otro SI NO

11. Puede recojer, oprimir, teclear, o por otra parte trabajar principalmente con sus dedos en Iugar de su mano entera

12. Puede aplicar presion a un objeto con sus dedos y palmas SI NO

13. Puede mantener su equilibrio para prevenir Ia caida al caminar o estar de pie, mientras agachandose o subiendo o bajando los

escalones con sus manos en Ia barandilla SI NO

14. Puede doblar su cuerpo hacia abajo y adelante doblando a Ia cintura (inclinandose) SI NO

15. Puede doblar sus piernas a la rodilla venir a un descanso en su rodilla(s)/arrodillandose SI NO

16. Puede doblar a Ia cintura rutinuamente SI NO

17. Si es necesario, puede estar de pie/sentado durante periodos largos del dia SI NO

18. Puede trabajar eficazmente y desempenar las tareas del trabajo en un ambiente ruidoso SI NO

19. Tiene usted una condicion o ha sostenido usted una herdia que tendria un efecto en su habilidad de desempenar

los deberes de esta posicion con o sin las acomodaciones razonables? SI NO

20. Tiene usted algun problema de su espalda o ha tenido usted alguna herida de su espalda alguna vez? SI NO

21. Ha tenido usted alguna vez algun problema serio de Ia muneca, incluyendo dano del movimiento repetitivo o el sindrome

del 'tunel carpiano'? SI NO

22. Ha tenido usted alguna vez una herida en sus manos, las munecas o los brazos? SI NO

23. Ha tenido usted alguna vez una herida en su espalda, el cuello, o los hombros? SI NO

24. Ha tenido usted alguna vez una herida en sus piernas, los tobillos, o los pies? SI NO

25. Si usted contestesto "si" a Ia pregunta #22, #23, o #24, fue necesario cirujia? SI NO

26. Tiene usted CUALQUIER problema de salud, o esta tomando ALGUNA medicacion que podria afectar su habilidad de

desempenar las funciones del trabajo? SI NO

27. Tiene usted ALGUNA alergia que lo restringiria de trabajar en ciertos ambientes o desempenar ciertas funciones del trabajo? SI NO

SI CONTESTO SI A LAS PREGUNTAS 19-27 POR FAVOR EXPLIQUE CON MAS DETALLE:

Nombre Firma Fecha

Department of the Treasury Internal Revenue Service

Employee's Withholding Certificate 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. (e) First name and middle intial Last name

Does your name match the name on your social security card? not. to ensure you get credit for your carrings contact SSA at 500-772-1213 or go to waw. $58 gov. Single or Married filing separately Married filing jointly or Quallying surviving spouse Head of household (Check only e "re unmarried and pay more than half the costs of keeping so 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, other details. and privacy. Step 2: 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. Multiple Jobs or Spouse Do only one of the following. Works (a) Reserved for future use. (b) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below; or (c) 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 is generally more accurate than (b) if pay at the lower paying job is more than half of the pay at the higher paying job. Otherwise, (b) is more accurate TIP: If you have self-employment income, see page 2. 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: If your total income will be $200,000 or less ($400,000 or less if married filing jointly): Claim Multiply the number of qualifying children under age 17 by $2,000 $ Dependent Multiply the number of other dependents by $500 and Other Add the amounts above for qualifying children and other dependents. You may add to this the amount of any other credits. Enter the total here3 Step 4 (a) Other income (not from jobs If you want tax withheld for other income you (optional):expect this year that won't have withholding, enter the amount of other income here. This may include interest, dividends, and retirement income 4(a) (b) Deductions. if you expect to claim deductions other than the standard deduction and want to reduce your withholding. use the Deductions Worksheet on page 3 and enter the result here 4(b)

(c) Extra withholding. Enter any additional tax you want withheld each pay period

Under penalties of perjury. declare that this certificate to the best of my knowledge and belief, is true. correct, and complete.

Employment Eligibility Verification

Department of Homeland Security U.S. Citizenship and Immigration Services

START HERE: Employers must ensure the form instructions are available to employees when completing this form. Employers are liable for failing to comply with the requirements for completing this form. See below and the Instructions. ANTI-DISCRIMINATION NOTICE: All employees can choose which acceptable documentation to present for Form I-9. Employers cannot ask employees for documentation to verify information in Section 1. or specify which acceptable documentation employees must present for Section 2 or Supplement B. Reverification and Rehire. Treating employees differently based on their citizenship, immigration status, or national origin may be illegal. Section 1. Employee Information and Attestation: Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment but not before accepting a job offer. Other Last Names Used (* any) Middle Initial (f any) First Name (Given Name) Last Name (Family Name)

City Town Apr. Number (if any)

I am aware that federal law provides for imprisonment and/or fines for false statements, or the use of false documents, in connection with the completion of this form. I attest, under penalty of perjury. that this information, including my selection of the box attesting to my citizenship or immigration status, is true and correct

Check one of the following boxes to affest to your citizenship or immigration status (See page 2 and of the

1. A clizen of the United States 2. A moncitizen national of the United States (See Instructions 3. A lawful permanent resident (Enter USCIS or A-Number 4. A noncitizen (other than Item Numbers 2. and 3 above authorized to work until (exp. date, if any) , you check item Number 4. enter one of these

# preparer and/or translator assisted you in completing Section 1. that person MUST complete the Preparer and/or Translator Certification on Page 1 Section 2. Employer Review and Verification: Employers or their authorized representative must complete and sign Section 2 within three business days after the employee's first day of employment and must physically examine, or examine consistent with an alternative procedure authorized by the Secretary of DHS, documentation from List A OR a combination of documentation from List B and List C. Enter any additional documentation in the Additional Information box: see Instructions List AListList C

Issuing Authority Document Number (f any) Expiration Date (I any) Document Title 2 (if any) Issuing Authority Document Number (if any) Expiration Date (if any) Document Title 3 (if any) Issuing Authority Document Number (f any)

Certification: lattest, under penalty of perjury. that (1) have examined the documentation presented by the above-eamed employee, (2) the above-listed documentation appears to be genuine and to relate to the employee named, and (1) to the best of my knowledge, the employee is authorized to work in the United States.