PSTAFFINGPOWER HOUSE

Are you entitled to work in the United States?esto

Have you been convicted of a felony or been incarcerated in connection with a felony in the past seven years?esNo

Reason for Leaving May We Contact

Other List any applicable special skills, training or proficiencies. Personal References

Disclaimer By signing, I hereby certify that the above information, to the best of my knowledge, Signature is correct. I understand that falsification of this information may prevent me from being hired or lead to my dismissal if hired. I also provide consent for former employers to be contacted regarding work records.

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. (a) First name and middle initialLast name

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.

Single or Married filing separately Married filing jointly or Qualifying surviving spouse Head 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, and when to use the estimator at www.irs.gov/W4App. 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) Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3-4 If you or your spouse have self-employment income, use this option; or (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

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): 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 3 this the amount of any other credits. Enter the total here (a) Other income (not from jobs If you want tax withheld for other income you Step 4 expect this year that won't have withholding, enter the amount of other income here. (optional): 4(a) This may include interest, dividends, and retirement income Other Adjustments (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 4(b) (c) Extra withholding. Enter any additional tax you want withheld each pay period

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

For Privacy Act and Paperwork Reduction Act Notice, see page 3.

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 beillegal. 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.

Middle Initial (if any) Other Last Names Used (if any)

Apt. Number (if any)City or Town

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 attest to your citizenship or immigration status (See page 2 and 3 of the instructions:

1. A citizen of the United States

2. A noncitizen 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) If you check Item Number 4., enter one of these:

If a preparer and/or translator assisted you in completing Section 1, that person MUST complete the Preparer and/or Translator Certification on Page 3. Section2.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 B List AList C

Check here if you used an alternative procedure authorized by DHS to examine documents

Certification: I attest, under penalty of perjury, that (1) I have examined the documentation presented by the above-named employee, (2) the above-listed documentation appears to be genuine and to relate to the employee named, and (3) to the best of my knowledge, the employee is authorized to work in the United States.

For reverification or rehire, complete Supplement B, Reverification and Rehire on Page 4.

All documents containing an expiration date must be unexpired. * Documents extended by the issuing authority are considered unexpired. Employees may present one selection from List A or a combination of one selection from List B and one selection from List C. Examples of many of these documents appear in the Handbook for Employers (M-274

Documents that Establish Both Identity and Employment Authorization

ORDocuments that Establish Identity AND

1. U.S. Passport or U.S. Passport Card 2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551) 3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine- readable immigrant visa 4. Employment Authorization Document that contains a photograph (Form I-766) 5. For an individual temporarily authorized to work for a specific employer because of his or her status or parole: a. Foreign passport; and b. Form I-94 or Form I-94A that has the following: (1) The same name as the passport; and (2) An endorsement of the individual's status or parole as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form. 6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address 2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address 3. School ID card with a photograph 4. Voter's registration card 5. U.S. Military card or draft record 6. Military dependent's ID card

Documents that Establish Employment Authorization 1. A Social Security Account Number card, unless the card includes one of the following restrictions:

(1) NOT VALID FOR EMPLOYMENT (2) VALID FOR WORK ONLY WITH INS AUTHORIZATION (3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION

2. Certification of report of birth issued by the Department of State (Forms DS-1350,

3. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal

7. U.S. Coast Guard Merchant Mariner Card 8. Native American tribal document

4. Native American tribal document

9. Driver's license issued by a Canadian government authority

For persons under age 18 who are unable to present a document listed above:

10. School record or report card 11. Clinic, doctor, or hospital record 12. Day-care or nursery school record

5. U.S. Citizen ID Card (Form I-197) 6. Identification Card for Use of Resident Citizen in the United States (Form I-179) 7. Employment authorization document issued by the Department of Homeland Security For examples, see Section 7 and Section 13 of the M-274 on uscis.gov/i-9-central. The Form I-766, Employment Authorization Document, is a List A, Item Number 4. document, not a List C document.

May be presented in lieu of a document listed above for a temporary period. For receipt validity dates, see the M-274.

Receipt for a replacement of a lost, stolen, or damaged List A document.

Form I-94 issued to a lawful permanent resident that contains an I-551 stamp and a photograph of the individual.

Form I-94 with "RE" notation or refugee stamp issued to a refugee.