Online Application

EMPLOYMENT HISTORY
CURRENT JOB:
Company
Company or Supervisor's Phone
Address
Supervisor
Job Title
Starting Salary:
Ending Salary:
Responsibilities
Date Started
Date You Left
Reason for Leaving
May we contact your current supervisor for a reference?

YesNo
PREVIOUS JOB:
Company
Company or Supervisor's Phone
Address
Supervisor
Job Title
Starting Salary:
Ending Salary:
Responsibilities
Date started
Date you left
Reason for Leaving
May we contact your previous supervisor for a reference?

YesNo

Please list (2) personal references
Full Name*
Phone No.*
Years Known*
Address*
Relationship*
Full Name*
Phone No.*
Years Known*
Address*
Relationship*

Applicant's Name*

First NameLast Name
I certify that the answers given herein are true and complete to the best of my knowledge.
I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.
This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant
wishing to be considered for employment beyond this time period should inquire as to whether or not applicants are being accepted at that time.
I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the employee may resign at any time and the Employer will may discharge Employee at any time with or without cause. It is further understood that this "at will" employment
relationship may not be changed by any written document or by conduct unless an authorized executive of this
organization specifically acknowledged such change in writing.
In the event of employment, I understand that false or misleading information given I my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of this employer.

By signing below, the undersigned hereby authorizes Role Model Vision LLC. or its agents to obtain any and all information that pertains to my eligibility for employment. This information will include, but is not limited to, criminal records, drug testing, credit history, employment verification, social security number verification and driving records. I understand that Role Model Vision LLC uses E-Verify for 1-9 verification. I also understand that the information below regarding sex, race, and date of birth has been requested for the sole purpose of gathering the above information correctly and will not be used to discriminate against me in violation of any law.

I state that the information above is accurate to the best of my knowledge. I also understand that the information about my background may contain negative information about my character and style of living. This releases any liability against the company or its acting agents. The authorization may be used in copy form.
Signature*

Clear
Today's Date*

MonthDayYear
Date

W9

REQUEST FOR TAXPAYER IDENTIFICATION NUMBER AND CERTIFICATION
Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.*

First NameMiddle NameLast Name
2 Business name/disregarded entity name, if different from above*
Check appropriate box for federal tax classification; check only one of the following seven boxes*

Individual/sole proprietor or single – member LLCC CorporationS CorporationPartnershipTrust/EstateLimited Liability CompanyOther
*IF* you entered Limited liability company, above. Enter the tax classification (C=C corporation, S=S corporation, P=partnership)
Note: for a single – member LLC, that is disregarded, do not check LLC; check the appropriate box in the line above the tax classification of the single – member owner
Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3.): Exempt payee code (if any)
Exemption from FATCA reporting code (if any)
(Applies to accounts maintained outside the U.S)
Address*

5 Address (number, street, and apt. or suite no.)

Street Address Line 2

6 City, state, and ZIP codeState / Province

Postal / Zip Code
Requester's name and address (optional)
List account number(s) here (optional)
Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given online one to avoid backup withholding. For individuals, this is generally your Social Security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see how to get a TIN on page 3.

Note: If the account is in more than one name, see the instructions for line, one, and the chart on page 4 for guidelines on whose number to enter.
Social Security Number
e.g. 123-45-6789
OR Employer Identification Number
e.g. 12-3456789
Certification

Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
2. I am not subject to back up withholding because
  1. I am exempt from back up, withholding, or
  2. I have not been notified by the Internal Revenue Service (IRS) that I am subject to back up withholding as a result of a failure to report all interest or dividends, or
  3. The IRS has notified me that I am no longer subject to back up withholding; and
3. I am a US citizen or other US person (defined below)
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item to above if you have been notified by the IRS that you are currently subject to back up withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage, interest, paid, acquisition, or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3.
Signature of U.S. person*

Clear
Date*

MonthDayYear
Date
General Instructions (for W9 form above)

Section references are to the Internal Revenue Code unless otherwise noted.

Future developments. Information about developments affecting form W-9 (such as legislation enacted after we release it) is at www.irs.gov/fw9

Purpose of Form

An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your Social Security number (SSN), individual taxpayer identification number (ITIN), adoption, taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount, reportable on an information return. Examples of information returns, include, but are not limited to, the following:
- Form 1099-INT (interest, earned or paid)
- Form 1099-DIV (dividends, including those from stocks or mutual funds)
- Form 1099-MISC (various types of income, prizes, awards, or gross proceeds)
- Form 1099-B (stock or mutual fund sales and certain other transactions by brokers)
- Form 1099-S (proceeds from real estate transactions)
- Form 1099-K (merchant card and third party network transactions)
- Form 1098 (home mortgage interest). 1098-E (student loan interest), 1098-T (tuition)
- Form 1099-C (canceled debt)
- Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person Qncluding a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TTN, you might be subject to backup withholding. See What is backup withholding? on page 2.
  By signing the filled-out form, you:
  1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued),
  2. Certify that you are not subject to backup withholding. or
  3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partner,sh1p income from a U.S. trade or business is not subject to the
  witholding tax on foreign partners' share of effectively connected Income, and
  4. Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. See What Is FATCA reporting? on page 2 for further information.

ROLE MODEL VISION LLC Vendor Payment Direct Deposit (ACH) Authorization Form
Vendor Name

First NameLast Name
Vendor Number
Vendor email address
example@example.com
Bank Name
Bank routing number (ABA #)
Vendor bank account #
Vendor bank account type (Enter "C" for checking OR "S" for Savings)
Agreement
I hereby authorize the ROLE MODEL VISION LLC to electronically
deposit amounts owed to me for services provided to the ROLE MODEL VISION LLC via direct deposit to my account (this includes my authorization to reverse any entries made in error.)
I understand that an unforeseen delay in processing by any outside entity (automated clearing house or financial institution) due to computer down-time, power outages, or any other unavoidable occurrences might affect the date of deposit of funds to my account.
This authorization is to remain in effect until the ROLE MODEL VISION LLC has received written notice of my intent to change/terminate this agreement or at the discretion of the ROLE MODEL VISION LLC.
The ROLE MODEL VISION LLC must receive my written notification of any financial institution changes (including closing of accounts) at least 15 days prior to the change in order to change/terminate this direct deposit authorization.
I will not hold the ROLE MODEL VISION LLC responsible for delay, loss or misapplication of funds due to incorrect or incomplete information supplied by me or my financial institution.
Vendor Approval
Signature

Clear
Date

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Should be Empty:

EMPLOYMENT HISTORY

CURRENT JOB:

PREVIOUS JOB:

W9

ROLE MODEL VISION LLC Vendor Payment Direct Deposit (ACH) Authorization Form

Vendor Approval