Employment Application

Employment Application
NEW EMPLOYEE ORIENTATION PACKET

Welcome to Quality Business Solutions, Inc.!
Quality Business Solutions, Inc.(QBS) is a Professional Employer Organization that provides Human Resource services including but not limited to payroll processing, benefits administration, and employment compliance. We have contracted with your present employer to provide these services. Therefore, we are the employer-of-record and should be listed as your employer for employment verification purposes. The
client for whom you perform your job will provide you direction in your day-to-day duties.

Enclosed you will find the necessary documents that must be signed and received by Quality Business Solutions, Inc. before your paychecks are processed. These documents are mandatory according to federal and state laws.

Please sign below to acknowledge that Rock Staffing, Inc. has my permission to share information in my personnel file as it relates to employee new hire information, tax filing status, any mandatory deductions or garnishment orders to Quality Business Solutions, Inc. (QBS) for the purpose of enrolling employees into the QBS HRIS system for the handling of payroll, benefits, tax reporting, etc.

We encourage you to call us with any questions at any time during our
employment relationship (877) 834-3985.
Signature of Employee *

Clear
Print Name *

First Name Last Name
Date *

DRUG FREE WORKPLACE POLICY
Quality Business Solutions, Inc. is committed to conduct its business with high regard for the health and safety of its employees, clients, their customers and suppliers, the protection of its assets and the maintenance of the productive work environment. In keeping w ith this commitment, employees and job applicants may be asked to provide body substance samples (i.e. urine and/or blood) to determine the use of: amphetamines, barbiturates, marijuana, cocaine, opiates, phencyclidine (PCP) and alcohol. Quality Business Solutions, Inc. will take all reasonable precautions to protect the confidentiality of all substance abuse test results. Tests may be conducted in any of the following situations:

PRE-EMPLOYMENT – As a pre-qualification to assuming any position, prospective employees may be required to provide a body fluid for testing.

REASONABLE CAUSE – Testing of this kind occurs when workplace behavior, which by objective observation, indicates that an employee may be imp aired or under the influence of drugs or alcohol.

POST ACCIDENT – Any employee/sub-contractor who is involved in a serious incident or accident while on duty, whether on or off the employer’s premises, may be asked to provide a body substance sample.

RANDOM TESTING – All employees will be subject to random testing at any time without notice.

Any employee who refuses to submit testing will be treated in accordance with the company’s disciplinary procedures concerning insubordination.

------QUALITY BUSINESS SOLUTIONS, INC IS A DRUG FREE WORKPLACE------

I have read and understand Quality Business Solutions, Inc. concerning drugs in the workplace.
Signature of Employee *

Clear
Date *

WORK-RELATED INJURY/ ILLNESS REPORTING
When a work-related injury or accident occurs, you are to report it to your supervisor as soon as possible following the incident or to Quality Business Solutions, Inc . at (877) 834-3985. Failure to report the accident/injury in a timely fashion could dela y insurance company payment of medical bills, and/or wages, or result in the denial of the claim. I acknowledge that I have read this no tice and I am aware of the potential consequences for failure to report a work-related injury or accident in a timely fashion. In the event a workplace injury occurs I understand that my social security numbe r is a valid and correct number, otherwise benefits will not be paid on my behalf.
Signature of Employee *

Clear
Date *
Email and Text Messaging Authorization
By filling out the below form, I am authorizing Rock Staffing to send me future written correspondence regarding my employment via email and/or text messaging. My email and/or text messaging authorization does not obligate Rock Staffing to communicate with me by email and/or text messages to my cell phone or cease non-electronic communication.

By signing below, I acknowledge and agree to the Terms and Conditions above.
Signature of Employee *

Clear
Date *

NEW HIRE INFORMATION
The following information is the minimum required in order to input a new employee into the QBS payroll system. A QBS Orientation Packet must be completed by each new employee immediatley upon hire and then forwarded to QBS within 2 business days.

All paperwork must be received by QBS before the employee's first paycheck is processed or they are covered by workers comp; otherwise QBS reserves the right to suspend payroll for any employee due to missing or incomplete paperwork.
SSN *
Social Security Number
Date of Birth *

Month Day Year
Date
Name *

First Name Middle Name Last Name Suffix
Address *

Street Address

Street Address Line 2

City State

Zip Code
Home Phone *

Area Code Phone Number
Mobile Phone

Area Code Phone Number
Email
example@example.com

EMERGENCY CONTACT INFORMATION
Person to Notify *
Relationship to Employee *
Phone Number *

Area Code Phone Number
EQUAL OPPORTUNITY EMPLOYER STATEMENT
This company is an Equal Opportunity Employer. We do not and will not discriminate in employment and personnel practices on the basis of race, sex, age, handicap, religion, national origin, or any other basis prohibited by applicable law. Hiring, transfering and promotion practices are performed without regard to the above listed items.
Signature of Employee *

Clear
Date
NOTICE OF UNEMPLOYMENT
Any employee will be presumed to have voluntarily left employment without good cause if the employee does not contact the local branch office where they initially submitted their employment application for reassignment upon completion of an assignment or layoff. Failure ot call in available each week to your local branch may result in denial of benefits.
Signature of Employee *

Clear
Date *

Direct Deposit

Authorization Agreement for Direct Deposit
Name *

First Name Middle Name Last Name Suffix
Would you like to enter Direct Deposit information at this time? *

Yes No

Direct Deposit Section
SSN *
Social Security Number
Address

Street Address

Street Address Line 2

City State

Zip Code
Phone Number

Area Code Phone Number
Financial Institution
Transit/ABA No.
(Must have copy of check or banks phone number)
Account Number
(Please attach a voided check. A copy will be fine.)
Account Type

Checking Account Savings Account

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I hereby authorize Quality Business Solutions, Inc., to initiate credit entries to my bank account indicated above, and I authorize the financial institution named above to process said credit entries. This authority is to remain in full force and effect until Quality Business Solutions, Inc., has received written notification from me of its termination in such manner as to afford Quality Business Solutions, Inc. and the financial institution a reasonable opportunity to act on it.
Signature of Employee *

(Signature MUST be that of a signer on the account) Clear
Date *

MEDICAL & DENTAL INSURANCE DISCLAIMER

Complete only if you are (1) eligible for coverage that is available and (2) do not wish to participate in the plans at this time.
Group medical and dental insurance is available to full-time employees, in certain geographic areas, that consistently work at least thirty (30) hours per week. It is the responsibility of each eligible employee to apply or waive coverage within 31 days from the date of hire or from the date of a change to full-time status.

PLEASE NOTE: Eligible employees may apply for or change their coverage for themselves and their dependents at a later date in the following circumstances: annual open enrollment or a change in family status (defined as marriage, divorce, legal separation, death, birth or adoption of a child, loss of other coverage, major change in other coverage, or eligibility for Medicare). In the event of a change in family status, it is the employee’s responsibility to notify the employer within 30 days from the date of the change and to provide documented proof. Other insurance plan stipulationsmay apply.
Do you wish to participate in the group health plans at this time? *

Yes No
“At this time I hereby waive group health coverage for...”
Check all that apply

Employee Spouse Dependents
Reason for Waiving Coverage

Do not wish to have coverage at this time Covered by other insurance (complete the following)
Name of Insured
Insurance Company
Signature of Employee *

Clear
Date *

RETURN TO WORK POLICY
QBS is committed to providing and promoting a safe and healthy workplace for our employees. Preventing accidents, injuries and illnesses is our primary objective. When an employee is injured on the job, QBS will use our return-to-work process to assist the employee in returning to work as soon as medically feasible. We will arrange for immediate, appropriate medical attention for employees who are injured on the job. We will attempt to create opportunities for them to return to safe, transitional work assignments as soon as medically possible. When a light duty position is not available within a location QBS will utilize local nonprofits to assist in transitioning the employee back into the workforce. The process may have different names (return-to-work program, modified work assignments, transitional work); however, our goal remains the same: to return injured employees to safe work. Our ultimate goal is to return our injured employees to their original jobs. If an injured employee is unable to perform all the tasks of the original job, QBS will make every effort to provide a transitional work assignment that meets the injured worker’s capabilities. The success of this process involves the combined efforts of management, employees, our designated medical provider(s) and our workers’ compensation insurance carrier.
Employee Signature *

Clear
Date *
RECORDS/WAGE INFORMATION AUTHORIZATION
I authorize any physician, medical practitioner, hospital, clinic, other health facility or employer or employer representative to release any and all medical and non-medical information in its possession about me to Next Level Administrators, LLC., or its legal representative. Medical information means all information in the possession of or derived from providers of healthcare regarding the medical history, mental or physical condition, or treatment of me.

I know that I may request and receive a copy of this authorization.

I agree that a photocopy of this authorization shall be as valid as the original.

I agree that this authorization shall be valid for two and one-half years from the date shown below.
Employee Signature *

Clear
Date *

Form W-4

An image of Form W-4 is displayed below. This image is meant to be used for informational purposes only. You will be required complete the Form W-4 in the section below the image. Please use the information from the image to help you complete this section.
W-4 Employee's Withholding Certificate
Step 1: Enter Personal Information
Name *

First Name Middle Initial Last Name
SSN *
Social Security Number
Does your name match the name on your socia security card? If not, to ensure you get credit for your earnings, contact SSA at 800-772-1213 or go to www.ssa.gov.
Address *

Street Address

Street Address Line 2

City State

Zip Code
Marital Status *

Single (or Married filing separately) Married filing jointly (or Qualifying Widow(er)) Head of Household
Note: If married, but legaly separated, or spouse is a nonresident alien, check the "Single" box.
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, when to use the online estimator, and privacy.
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 these jobs.
Do only one of the following.

(a) Use the estimater at www.irs.gov/W4App for the most accurate withholding for this step (and Steps 3-4); or

.

.

(b) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding; or
(c) If there are only two jobs total, you may check here. Do the same on Form W-4 for the other job. This option is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld.

Only two jobs total
TIP: To be accurate, submit a 2020 Form W-4 for all other jobs. If you (or your spouse) have self-employment income, including as an independent contractor, use estimator.

Complete Steps 3-4(b) on Form W-4 for only ONE of these jobs. Leave those 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 Dependents
If your 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
Multiply the number if other dependents by $500
3 Add the amounts above and enter the total here
Step 4 (optional): Other Adjustments
4(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 the other income here. This may include interest, dividends, and retirement income
4(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 (see embedded form above) and enter the result here
4(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, (Form W4 Section of this application) to the best of my knowledge and belief, it is true, correct, and complete. *Note: this form is not valid unless you sign it.
Employee Electronic Signature for Form W-4 *

Clear
DateTime *
Rock Staffing Branch Location

STATE OF GEORGIA EMPLOYEE'S WITHHOLDING ALLOWANCE CERTIFICATE

An image of Form G-4 is displayed below. This image is meant to be used for informational purposes only. You will be required to enter your total number of allowances from Form G-4 in the section below the image. Please use the information from the image to help you obtain your total number of allowances.
1a. Your Full Name *

First Name Middle Name Last Name
1b. SSN *
Social Security Number
2. Home Address *

Street Address

Street Address Line 2

City State

Zip Code
3. MARITAL STATUS

(If you do not wish to claim an allowance, enter "0" in the brackets beside your marital status.)
A.Single:
Enter 0 or 1
B. Married Filing Joint, both spouses working:
Enter 0 or 1
C. Married Filing Joint, one spouse working:
Enter 0 or 1 or 2
D. Married Filing Separate:
Enter 0 or 1
E. Head of Household:
Enter 0 or 1
4. DEPENDENT ALLOWANCES *
5. ADDITIONAL ALLOWANCES
(Worksheet on G-4 must be completed)
6. ADDITIONAL WITHHOLDING ($)
7. Letter Used *
(Marital Status A,B,C,D or E)
TOTAL ALLOWANCES *
(Total of Lines 3-5)
8. EXEMPT: (Do not complete lines 3-7 if claiming exempt) Read the line 8 instructions on page 2 before completing this section.
Check Here If Either Apply

a) I claim exemption from withholding because I incurred no Georgia income tax liability last year and I do not expect to have a Georgia income tax liability this year b) I certify that I am not subject to Georgia withholding because I meet the conditions set forth under the Servicemembers Civil Relief Act as provided on page 2.
If you checked b)
My State of residence
If you checked b)
My spouse's (servicemember) State of residence
The states of residence must be the same to be exempt
I certify under penalty of perjury that I am entitled to the number of withholding allowances or the exemption from withholding status claimed on this form G-4. Also, I authorize my employer to deduct per pay period the additional amount litsed above.
Employee Signature *

Clear
Date *

Employment Eligibility Verification - I9
Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services
►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.
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 *

Last Name (Family Name) First Name (Given Name) Middle Initial
Other Last Names
Other Last Names Used (if any)
Address *

Address (Street Number and Name)

Apt. Number

City or Town State

Zip Code
Date of Birth (mm/dd/yyyy) *

Month Day Year
Date of Birth
U.S. Social Security Number *
Social Security Number
Employee's E-mail Address
example@example.com
Employee's Telephone Number *

Area Code Phone Number
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.

I attest, under penalty of perjury, that I am (check one of the following boxes):
I attest, under penalty of perjury, that I am (check one of the following boxes): *

1. A citizen of the United States 2. A noncitizen national of the United States (See instructions) 3. A lawful permanent resident (List Alien Registration Number/USCIS Number below) 4. An alien authorized to work (List expiration date below)

Alien Registration Number/ USCIS Number
Alien Work Expiration Date

Month Day Year
(expiration date, if applicable, mm/dd/yyyy):
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.
1. Alien Registration Number/USCIS Number:
OR
2. Form I-94 Admission Number:
OR
3. Foreign Passport Number:
Country of Issuance:

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Employee Signature *

Clear
Date *
Preparer or Translator Certification *

I did not use a preparer or translator A preparer(s) and/or translator(s) assisted the employee in completing Section 1
(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)

I9 Preparer
Signature of Preparer or Translator (Only Complete if a preparer assisted you with section 1)

Clear
Today's Date (Only Complete if a preparer assisted you with section 1)
Preparer Name (Only Complete if a preparer assisted you with section 1)

Last Name (Family Name) First Name (Given Name)
Preparer Address (Only Complete if a preparer assisted you with section 1)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Download 2 Forms of Identification

Browse Files

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Employment Application

NEW EMPLOYEE ORIENTATION PACKET

DRUG FREE WORKPLACE POLICY

WORK-RELATED INJURY/ ILLNESS REPORTING

Email and Text Messaging Authorization

NEW HIRE INFORMATION

EMERGENCY CONTACT INFORMATION

EQUAL OPPORTUNITY EMPLOYER STATEMENT

NOTICE OF UNEMPLOYMENT

Direct Deposit

MEDICAL & DENTAL INSURANCE DISCLAIMER

Dependent Information

RETURN TO WORK POLICY

RECORDS/WAGE INFORMATION AUTHORIZATION

Form W-4

W-4 Employee's Withholding Certificate

STATE OF GEORGIA EMPLOYEE'S WITHHOLDING ALLOWANCE CERTIFICATE

Employment Eligibility Verification - I9

Employment Eligibility Verification Department of Homeland Security