LUMEN STAFFING - Application Form

1. FORM I9 - W4 - W9
Important *

All personal information provided herein (Name, Email, Phone, Address, and SSN) will be used by LumenStaffing for year-end tax reporting.

LumenStaffing will send these tax forms to applicant using the email address or physical address provided in this application.

It is the applicant's duty to provide LumenStaffing with updated information should any of these details change.
FORM I9
Employment Eligibility Verification

Department of Homeland SecurityU.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.
Name

First NameMiddle InitialLast Name
Other Last Name Used (If any)
Address

Street Address

Apt. Number (if any)

CityState

Zip CodeCountry
Date of Birth (mm/dd/yyyy)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
U.S. Social Security Number
Ex: 123456789
Employee's Email Address
example@example.com
Employee's Telephone Number
Format: (000) 000-0000.
Check one of the following boxes to attest to your citizenship or immigration status (See page 2 and 3 of the instructions.):
a . If you choose option 3: A lawful permanent resident, please enter USCIS or A-Number)
USCIS A-Number ( If you are A lawful permanent resident - option 3)
b. If you choose option 4: An alien authorized to work , please enter Expiration date And USCIS A-Number OR Form I94-Admission Number OR Foreign Passport Number AND County of Issuance
Exp. date, if any - If you are "An alien authorized to work"
date: MM/DD/YYYY
USCIS A-Number
Form I-94 Admission Number
Foreign Passport Number and Country of Issuance
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.
Signature of Employee
Today's Date (mm/dd/yyyy)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Business Name
Business Address
If a preparer and/or translator assisted you in completing Section 1, Please STOP filling the form and contact Lumen Staffing for a paper form.

FORM W4
Employee's Withholding Certificate
Step 1: Enter Personal Information
Name

First Name and middle initialLast 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.
Filing status
TIP: Consider using the estimator at www.irs.gov/W4App to determine the most accurate withholding for the rest of the year if: you are completing this form after the beginning of the year; expect to work only part of the year; or have changes during the year in your marital status, number of jobs for you (and/or your spouse if married filing jointly), dependents, other income (not from jobs), deductions, or credits. Have your most recent pay stub(s) from this year available when using the estimator. At the beginning of next year, use the estimator again to recheck your withholding.

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: 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 the 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
Check this box only if you are going with option c above
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 Dependent and Other Credits
1) Fill out if your income will be $200,000 or less ($400,000 or less if married filing jointly)
Enter the number of children you can claim as dependants under the age of 17.
This is the number of children under the age of 17 you entered above multiplied by $2,200
Enter the number of other dependents you wish to claim such as an older child or qualifying relative.
This is the number of other dependents you entered above multiplied by $500.
2) Add the amounts above for qualifying children and other dependents. You may add to this the amount of any other credits. Enter the total here
Step 4 (optional): Other Adjustments
(a) Other income (not from jobs). If you want tax withheld for other income you expect this year that won't have withholding, enter the amount of other income here. This may include interest, dividends, and retirement income
(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
(c) Extra withholding. Enter any additional tax you want withheld each pay period.
Step 5: Sign Here
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.)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Business Name
Business Address
EIN

FORM W9
Request for Taxpayer Identification Number and Certification
Before you begin. For guidance related to the purpose of Form W-9, see Purpose of Form, below.
1. Name of entity/individual. An entry is required. (For a sole proprietor or disregarded entity, enter the owner's name on line 1, and enter the business/disregarded entity's name on line 2.)
2. Business name/disregarded entity name, if different from above.
3a. Check the appropriate box for federal tax classification of the entity/individual whose name is entered on line 1. Check only one of the following seven boxes.
In 3a, If you check the "LLC" box above. Please enter the appropriate code (C, S, or P) for the tax classification of the LLC, unless it is a disregarded entity. A disregarded entity should instead check the appropriate box for the tax classification of its owner.
In 3a, If you choose "Other" box above. Please enter detail in the textbox here.
3b.
4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):
Exempt payee code (if any)
Exemption from Foreign Account Tax Compliance Act (FATCA) reporting code (if any)
(Applies to accounts maintained outside of the United States.)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Requester's name and address (optional)
7 List account number(s) here (optional)
Part I Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 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 instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later.
Social security number
123-45-6789
Or Employer Identification number
12-3456789
Part II 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 backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and
3. I am a U.S. citizen or other U.S. person (defined below); and
  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 2 above if you have been notified by the IRS that you are currently subject to backup 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 for Part II, later.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

2. APPLICATION FORM
It is our policy to follow all applicable state and federal laws prohibiting discrimination in employment based on race, age, color, sex, religion, national origin, disability or other protected classifications.

Carefully read and answer all questions. You will not be considered employment if you do not completely answer all the questions on this application. You may attach a résumé, but all questions must be answered.
Position applying for
Personal Data
Name (first, middle, last)
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Cell phone number
Format: (000) 000-0000.
Email Address
example@gmail.com
Emergency Contact (Name/Phone#)
Date available

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Salary Desired
Ex: $15/h
Do you have a High School Diploma or GED?
Position Information
Full Time/Part Time
Day / Night
Swing / Over Night / Weekend
Status: Regular / Temporary
Are you authorized to work in the U.S. on an unrestricted basis?
Have you ever been convicted of a felony? (Convictions will not necessarily disqualify an applicant for employment.)
If Yes, please explain
Have you been told about the job's essential functions, or have you viewed a copy of the job description listing them?
Can you perform these essential functions of the job with or without reasonable accommodation?
You can upload your resume here (optional but recommended). The file size should be smaller than 5MB.

Cancelof
Signature

QUALIFICATIONS, please list any education or training you feel relates to the position applied for that would help you perform the work, such as schools, colleges, degrees, vocational or technical programs, and military training.

REFERENCES, please list three professional references not related to you, with full name, address, phone number, and relationship. If you don't have three professional references, then list personal, unrelated references.
References

please list three professional references not related to you, with full name, address, phone number, and relationship. If you don't have three professional references, then list personal, unrelated references.
Name
Address/City/State
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship
Work history
May we contact your present employer?
Job Title
Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Company Name
Supervisor's Name
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Duties:
Reason for Leaving
Starting Salary
Ending Salary
I certify that the facts set forth in this Application for Employment are true and complete to the best of my knowledge. I understand that if I am employed, false statements, omissions, or misrepresentations may result in my dismissal. I authorize the Employer to make an investigation of any of the facts set forth in this application and release the Employer from any liability. The employer may contact any listed references on this application.
I acknowledge and understand that the company is an "at will" employer. Therefore, any employee (regular, temporary, or other type of category employee) may resign at any time, just as the employer may terminate the employment relationship with any employee at any time, with or without cause, with or without notice to the other party.
Applicant Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please verify that you are human

3. ACKNOWLEDGEMENT FORM
ACKNOWLEDGEMENT AND AUTHORIZATION FOR BACKGROUND CHECK
I acknowledge receipt of the separate document entitled DISCLOSURE REGARDING BACKGROUND INVESTIGATION and SUMMARY OF YOUR RIGHTS UNDER FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of "consumer reports" and/or "investigative consumer reports" by Lumen Staffing at any time after receipt of this authorization and throughout my employment, as allowable by applicable law. To this end, I hereby authorize, without reservation, any law enforcement agency, employer, and insurance company to furnish any and all background information requested by (insert requesting company and address, followed by phone number, then website and/or Lumen Staffing. I agree that a facsimile ("fax"), electronic or photographic copy of this authorization shall be as valid as the original and I agree to receive any notices relating to my background check, electronically.
** New York applicants only: Upon request, you will be informed whether or not a consumer report was requested by the company, and if such report was requested, informed of the name and address of the consumer reporting agency that furnished the report. You have the right to inspect and receive a copy of any investigative consumer report requested by the company by contacting the consumer reporting agency identified above directly. By signing below, you acknowledge receipt of article 23-A of the New York Correction Law.
** New York City applicants only: By signing this form, you further authorize the company to provide you wit a copy of your consumer report, the New York City Fair Chance Act Notice form, and any other documents, to the extent of your consumer report, the New York City Fair Change Act Notice form, and any other documents, to the extent required by law, at the mailing address and/or email address you provide to the company.
** Washington State applicants only: You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting act.
Full Name
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year

DRUG TEST ACKNOWLEDGEMENT FORM
I understand that as part of the company's policy, if there is an on-the-job accident or a near-miss, I am required to take a drug and alcohol test. I give my consent for this and acknowledge that if I test positive or refuse to take the test, it will result in my termination. I also release Lumen Staffing, LLC, its clients, and any clinic or individual involved in administering the test from any claims that may arise based on the results, or any actions taken because of those results.
I also understand that, after completing an assignment, it's my responsibility to check in with the branch office at least once every seven (7) days to confirm my availability for the next assignment. If I don't, it will be treated as a voluntary quit, which could affect my eligibility for unemployment benefits. If my assignment ends because of attendance issues, I will be let go from Lumen Staffing, LLC.
Additionally, I understand that there will be a $5 deduction from my first paycheck to cover the cost of administrative fees.
I acknowledge that I have read and understand the above statements regarding Lumen Staffing, LLC's policies and procedures for employment.
Print Name:
Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

EMPLOYEE ATTENDANCE POLICY ACKNOWLEDGMENT FORM
To maintain a productive and reliable work environment, it is essential that all employees report to work as scheduled. This form outlines the attendance policy and the consequences of failing to adhere to it.
Attendance Policy:
- Any unexcused absence or no-call/no-show may result in a written warning.
- Repeated unexcused absences may lead to suspension or termination.
- If you are unable to report to work, you must notify your supervisor or manager at least 2 hours prior to your shift.
- Failure to communicate and show up for work may result in immediate replacement without notice.
Consequences:

Consequences:

Violation	Consequence
1st unexcused absence	Verbal or Written Warning
2nd unexcused absence	Final Warning or Suspension
3rd unexcused absence	Termination / Replacement

By signing below, you acknowledge that you have read, understood, and agree to follow the attendance policy described above.
Employee Name:
Employee Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

SAFTETY CODE OF CONDUCT
As an employee of Lumen Staffing, LLC, I agree to read, understand and abide by the following Safety Codes of Conduct. The purpose of this outline is to review & inform you of your responsibility to each job or task with your personal safety in mind at work. Injury prevention takes a team effort, and this is part of Lumen's effort to communicate our expectations but also realize that it takes your personal commitment to stay injury-free. This listing is not meant to identify every risk or indicate every job function you may or may not perform. I certify that I will:
1. Follow safety rules and procedure established at the client facility.

2. Always inspect, wear and use personal protective equipment as required by the client.

3. Never perform any job I have not been trained or authorized to perform.

4. Lift properly to prevent strain injuries. This includes asking for assistance when needed, not ever reaching for product, pushing or pulling in a manner that doesn't cause harm or using mechanical means (such as a pallet jack) to help move loads.

5. Never cross the conveyor system except at designated areas.

6. Always wear your seatbelt on a forklift and keep your hands, legs, and feet inside the unit.

7. Keep an eye on the path ahead of me to watch for any trip hazards.

8. Read and comply with warning signs posted in the facility that will alert me to unsafe areas.

9. Use a box cutter provided only by the client in a safe manner by cutting in a direction away from body, arms, or hands. Request a new one should it become damaged or dull.

10. Ask for assistance in handling or movement of pallets. Never try to lift or move a pallet stacked above your chest level.

11. Identify 'blind corners or locations' in the work environment to safely move through the area.

12. Wear the required personal protective equipment where and when required.

13. No climbing in any rack that may cause me to slip and fall.

14. When walking or working on my workstation, I will allow the forklift operator the 'right-of-way'.

15. Immediately report any accident should one occur, immediately to my supervisor and Lumen Staffing staff within 24 hours.

16. Assist in keeping the work environment clean by picking up and disposing of debris or other materials in waste containers.

17. Never climb on a rack, material etc., that could cause you to fall. Only approved 'rolling ladders' can be used to pick up products at elevated heights.

18. Utilize the picking cart in a safe manner and watch out for my co-workers.

19. I will review the conveyor system for the location of emergency spots in the event one needs to be activated.

20. Report any conditions that could possibly contribute to an accident and notify the On-site Supervisor and/or client representative.
Employee Name
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Payroll Payment Authorization
Please complete this form to authorize your preferred payroll payment method. Return the completed form to payroll@lumenstaffing.com or drop it off at our office.
Employee Information
Full Name:
Employee ID (if any):
Payment Method (select one)
Payment Method
Bank Information (for Direct Deposit)
Bank Name:
Account Type:
Routing (ABA) Number:
Account Number:
Attach a voided check or a bank verification letter (optional but recommended). File size should be smaller than 4Mb in oder

Cancelof
Authorization
I hereby authorize Lumen Staffing, LLC to initiate automatic deposits to the bank account indicated above. I also authorize adjustments to correct any erroneous deposits and understand that I must notify payroll immediately of any changes to my account information. If this authorization is not valid, or if I request termination, I will provide written notice to payroll.
Employee Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Information Accuracy
- By submitting this application, I certify that all contact and personal information provided —including my email address, phone number, physical address, and Social Security Number (SSN) — is accurate.
- Duty to Update: I acknowledge that it is my sole responsibility to notify LumenStaffing of any changes to this information. If I am currently working for LumenStaffing, I must report these updates immediately. If I no longer work for LumenStaffing, I am required to continue reporting any changes for up to 365 days from my last day of employment. All updates must be submitted using the phone number or email address provided at lumenstaffing.net.
- Limitation of Liability: LumenStaffing shall not be held responsible for any failures, penalties, or errors resulting from my failure to provide updated contact or personal details.
I have read and agree to the Information Accuracy terms above.
Full Name
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Work Assignment Policy Acknowledgment
This policy outlines employee responsibilities regarding work assignments through Lumen Staffing.

Assignment Commitment
By accepting a work assignment, employees agree to report to work as scheduled and fulfill the duration of the assignment unless otherwise notified by Lumen Staffing or the client.

Early Departure / Job Abandonment
If an employee leaves an assignment before completion without prior notification or approval from Lumen Staffing, it will be considered job abandonment. Employees must notify Lumen Staffing immediately if they are unable to continue an assignment for any reason.

End of Assignment
When an assignment ends—whether due to completion or at the request of the client—the employee is responsible for contacting Lumen Staffing within 48 hours to request reassignment.

Failure to Contact
Failure to contact Lumen Staffing within 48 hours after the end of an assignment will be considered a voluntary resignation and may affect eligibility for unemployment benefits in accordance with applicable laws.

Communication Requirement
Employees must maintain communication with Lumen Staffing regarding attendance, schedule changes, or any issues related to their assignment.

By signing below, you acknowledge that you have read, understood, and agreed to comply with this policy.
Employee Name
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year

Alcohol & Drug Policy Acknowledgment
I understand that Lumen Staffing LLC prohibits employees from reporting to work, working, or remaining on Company or client premises while impaired by alcohol, illegal drugs, or other prohibited substances. The use, possession, consumption, distribution, or sale of alcohol or illegal drugs while working or on Company or client premises is prohibited.

I understand that Lumen Staffing LLC may require drug and/or alcohol testing in accordance with Company policy when there is reasonable suspicion of impairment, or following a workplace accident, near accident, or safety incident when there is a reasonable basis to believe that drugs or alcohol may have contributed to the incident.

I consent to drug and/or alcohol testing properly required under Company policy and agree to cooperate with the testing process. A confirmed positive test, refusal to test, tampering with or interfering with a test, on-duty use or possession of alcohol or illegal drugs, or other serious violation of this policy may result in disciplinary action, up to and including termination of employment.

I understand that being removed from work while an incident is reviewed does not, by itself, mean that a policy violation has been established or that my employment has been terminated.

By signing below, I acknowledge that I have read, understand, and agree to comply with Lumen Staffing LLC’s Alcohol and Drug Policy.
Employee Name
Employee Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Please verify that you are human
Should be Empty:

1. FORM I9 - W4 - W9

FORM I9

Employment Eligibility Verification

Section 1. Employee Information and Attestation

FORM W4

Employee's Withholding Certificate

Step 1: Enter Personal Information

Step 2: Multiple Jobs or Spouse Works

Step 3: Claim Dependent and Other Credits

Step 4 (optional): Other Adjustments

Step 5: Sign Here

FORM W9

Request for Taxpayer Identification Number and Certification

Part I Taxpayer Identification Number (TIN)

Part II Certification

2. APPLICATION FORM

Personal Data

Position Information

References

Work history

3. ACKNOWLEDGEMENT FORM

ACKNOWLEDGEMENT AND AUTHORIZATION FOR BACKGROUND CHECK

DRUG TEST ACKNOWLEDGEMENT FORM

EMPLOYEE ATTENDANCE POLICY ACKNOWLEDGMENT FORM

Attendance Policy:

Consequences:

SAFTETY CODE OF CONDUCT

Payroll Payment Authorization

Employee Information

Payment Method (select one)

Bank Information (for Direct Deposit)

Authorization

Information Accuracy

Work Assignment Policy Acknowledgment

Alcohol & Drug Policy Acknowledgment