New Employee Paperwork Summary - Intel · New Employee Paperwork Summary ... APPENDIX A TO...

New Employee Paperwork Summary

EMPLOYEE NAME __________________________________ WWID _____________________

Completed by New Hire

1. Appendix A / Employment Agreement

2. Information Supplement 1

3. Information Supplement 2

4. Code of Conduct Questionnaire

5. Intel Employee Agreement

6. New Employee Orientation Certification

7. Intel Retirement Plans Prior Service Questionnaire

8. New Hire Benefits Form

9. Medical Provider Network (MPN) Handbook

10. Data Protection Authorization for New Hires

Updated Forms ©Intel Corporation REV JAN 2016

APPENDIX A TO EMPLOYMENT AGREEMENT SECTION 5

Employee Name: ______________________________ WWID: ______________________

Do you own or control, in whole or in part, any Preexisting Employee Intellectual Property

(including patents and patent applications) that you are not licensing to the Intel Group, as

defined in Section 5 as Identified Employee Controlled Intellectual Property? (Do not answer

“Yes” for patents which your former employer or other party owns, but which merely name

you as an inventor.)

If yes, list such Identified Employee Controlled Intellectual Property (attach or specifically identify

relevant patents, patent applications, or similar disclosures):

Do you have an economic interest in any patents, pending applications or other Preexisting

Employee Intellectual Property that you do not own or control, for example patents or

applications owned by a University on which you are named an inventor?

If yes, list such Preexisting Employee Intellectual Property (attach or specifically identify relevant

patents, patent applications, or similar disclosures):

Attach additional sheets as necessary. Number of additional sheets attached: ____

Employee Signature: ___________________________

Date:_______________

Information Supplement

PLEASE PRINT

Complete all requested information. All information you provide will be handled in strict confidence.

EMPLOYEE NAME: ___________________________________________________________________________ LAST FIRST MIDDLE WORLDWIDE ID: ____________________SOCIAL SECURITY NUMBER: _____-____-______

HOME PHONE NUMBER: _______________________________________________________ EMERGENCY CONTACT: _______________________________________________________ NAME RELATIONSHIP PHONE NUMBER

Technology Transfer Control Information Intel works in technology areas that are subject to export controls by the United States government. Intel

must obtain authorization from the Bureau of Industry and Security, U.S. Department of Commerce, before

employing citizens from certain countries. This questionnaire is designed to assist Intel in determining

whether it must apply for an export license on behalf of a potential new hire. QUESTION 1 As of today’s date, are you one of the following:

• Citizen or Legal National of the United States; • Lawful Permanent Resident (PR) of the United States (Note: Only having an application for PR status

pending requires a “NO” answer.) • A person granted refugee status in the United States (Note: Only having public interest parole,

humanitarian parole, or temporary protected status requires a “NO” answer.) • A person granted asylum status in the United States (Note: Only having an asylum application

pending requires a “NO” answer)

□ YES □ NO

NOTE: Individuals in nonimmigrant visa status such as B, L, H visa status should answer NO. QUESTION 2 If your answer to Question 1 is “NO”, but you claim that you have authorization to work in the United States

on a full-time basis, please identify the basis for your right to work in U.S:

□E □F-1 □H-1B □H-3 □J-1 □L-1 □TN □EAD □O-1

Visa/work authorization: start date___________ expiration date________

Check, if applicable: □ Optional Practical Training □ Curricular Practical Training (If you checked either box, bring a copy of the I-20 form to NEO)

QUESTION 3 If your answer to Question 1 is “NO” to all the legal status categories, please answer the following:

• What is your citizenship? ___________________________________________________ • If you have multiple citizenship (i.e., citizenship in two or more countries), name the country in

which you have the most recent citizenship and provide the citizenship issuance date. ________________________________________________________________________

• If you have Permanent Residency (PR) in multiple countries (i.e., PR in two or more countries),

name the country in which you have the most recent PR and provide the PR issuance date. ________________________________________________________________________

I understand that any work assignment at Intel may be conditioned upon export license requirements

I CERTIFY THAT THE INFORMATION SUPPLIED IS TRUE AND CORRECT ___________________________________________________ _________________________________ EMPLOYEE SIGNATURE DATE Rev. 11/2010

Information Supplement, page 2 The following information is required for

confirmation of employment and/or benefit status:

EMPLOYEE NAME ________________________________

DATE OF BIRTH ___/____/____

MARITAL STATUS: □ SINGLE □ MARRIED GENDER: □ MALE □ FEMALE

_________________________________________________________

Intel’s Commitment to Diversity Our diversity is our strength. We want to be a workplace of choice for all people and we value the unique

perspectives offered by a diverse workforce. Intel does not discriminate on the basis of race, color, religion,

sex, national origin, ancestry, age, disability, veteran status, marital status, gender identity, gender

expression, or sexual orientation. This principal applies to all areas of employment: recruitment and hiring,

training, performance evaluations, promotions and transfers, compensation and benefits, and social and

recreational programs. We encourage and invite you to complete the information below. Your information is critical to our efforts in

complying with federal and state Equal Employment Opportunity record keeping, reporting, and other legal

requirements. While identifying is voluntary, Intel will also use this information to invite you to applicable

Intel events and related communications. Any information you provide will be kept confidential and will be

used only in accordance with legal requirements

What is your race? Please select all that apply. You may also select one race or ethnicity category that you

most closely identify with as primary:

□

Hispanic, Latino, or of Spanish Origin - A person having origins in any of the original

peoples of Cuba, Mexico, Puerto Rico, South or Central America, or other Spanish

culture or origin regardless of race.

□

American Indian or Alaska Native - A person having origins in any of the original

peoples of North and South America (including Central America), and who

maintain tribal affiliation or community attachment.

□

Asian - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

□

Black or African American - A person having origins in any of the black racial groups

of Africa.

□

Native Hawaiian or Other Pacific Islander - A person having origins in any of the

peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

□

White - A person having origins in any of the original peoples of Europe, the Middle

East, or North Africa.

HAVE YOU EVER SERVED IN THE U.S. MILITARY (ACTIVE, RESERVE, AND/OR NATIONAL GUARD?)

If YES the below is all about you.

Intel welcomes military veterans, active duty, and guard and reserves! We value your experience and know that the

military shares our values: discipline, quality, risk taking, results orientation, customer orientation, and great place to work.

More than simply words, they are something we live by each day. They speak to everyone within our diverse workforce,

and service members who have lived and breathed these values will do well at Intel. If you have served in the military, we

invite you to identify yourself below as a proud member of this community. Identifying your military status is voluntary

but it provides Intel with critical, relevant, and accurate data on our workforce which translates into enhanced results in

recruiting, retaining, promoting, and supporting our military employees. As a part of Intel’s military community, you can

choose to be involved in additional events, help build programs, and foster ongoing efforts.

Please check which category you fall into:

□

ACTIVE DUTY WARTIME OR CAMPAIGN BADGE VETERAN: You served on active duty in the U.S.

military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized.

□

NATIONAL GUARD OR RESERVE SERVICE: You are serving or served in the National Guard or Reserve but

were not called or drafted into active service by the U.S.

In addition, please check all that are applicable (you may check more than one category):

□

DISABLED MILITARY/VETERAN: You (a) were discharged or released from active duty because of a

service-connected disability, or (b) are entitled to compensation under laws administered by the

Secretary of Veterans Affairs.

□

RECENTLY SEPARATED MILITARY/VETERAN: You served on active duty within the last 3 years.

DATE OF MOST RECENT DISCHARGE: ___/____/____

http://www.intel.com/lifeatintel/values/




□

ARMED FORCES SERVICE MEDAL MILITARY/VETERAN: While serving on active duty, you participated in a

military operation for which an Armed Forces service medal was awarded.

Code of Conduct Questionnaire Intel Confidential

If you answer “Yes”, to Questions 1-2 below, you must review the Guidelines regarding Personal

Appointment of Intel Employees to Boards of Outside Organizations, and if required, complete an “Outside Directorship Conflict

of Interest Questionnaire” and follow the approval process outlined in the guidelines and Questionnaire. If

you answer “Yes”, to Questions 3-4 below, you must disclose to your manager, in writing, the existence

and nature of your outside relationship or employment and include your disclosure in this form (see

below).* These disclosures must be made within the first three weeks of employment, so that Intel can

determine if it creates an actual or perceived conflict of interest with Intel’s business interests.

1. Are you a member of a board of directors, board of advisers, government advisory commission or similar

governing or advisory body of a non-Intel company, academic institution, industry group, government entity

or non-profit organization? If the answer is “No”, please go to question 3.

If you answered “Yes”, please provide the name of the company/organization on whose board or

governing/advisory body you serve:

________________________________________________________________________________________

_______________

________________________________________________________________________________________

_______________ 2. If you answered “Yes” to question 1,

• Is this company/organization contemplating doing business with Intel as a vendor, purchaser, contractor

or otherwise? or • Have you participated in or attempted to influence any Intel decision involving this

company/organization?

No Yes

3. Are you currently employed or do you have any financial or business interest that could present a conflict (or

even the appearance of a conflict) with Intel’s interest, such as consulting, operating a personal business,

holding political office, etcetera, outside of Intel?

No Yes

No Yes

If you answered “Yes”, please provide the name of the employer and describe the nature of the financial or business Interest:

________________________________________________________________________________________

______________ ________________________________________________________________________________________

______________

4. If you answered “Yes” to question 3,

• Does this outside employment or financial or business interest relate to or resemble business

conducted at Intel? or • Could your outside employment or financial or business activity interfere – or even appear to

interfere – with your ability to make sound business decisions in the best interest of Intel?

No Yes

* Disclosure: 1. What external entity does this involve (name of customer, vendor, subcontractor, contingent worker, etc.)?

2. What is the entity’s business relationship with Intel (customer, vendor, partner, etc.)?

3. What is your association to the entity (investor, friend, family, ownership, etc.)?

4. How long have you had the association to the entity?

5. If you know someone at the entity, how long have they been at the entity and what is their role?

6. How is your contact at the entity associated with Intel business?

7. What is your role at Intel and could that role have any direct or indirect influence on Intel business with the

external entity (i.e are you involved in procurement, influence, or direct decisions related to this entity)?

8. What, if any, information do you use at Intel which may relate to the Intel association with the external entity.

(i.e. project/product information, procurement process, etc.)

____________________________________ ____________________________________ _____________

____________________________________

PRINTED NAME EMPLOYEE SIGNATURE DATE WORLDWIDE ID

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13 Distribution: White Copy – US Records CH3-171 Yellow Copy – Employee Pink Copy –US Records CH3-171

EMPLOYMENT AGREEMENT

In exchange for being employed by Intel Corporation or any of its subsidiaries, affiliates or

successors (collectively called “Intel”) in this Agreement, I agree to the following:

1. General Conduct. I will perform my assigned Intel duties and comply with all Intel policies, procedures, guidelines,

rules, and instructions, including Intel’s Code of Conduct, Employment Guidelines and Corporate

Information Security and Security policies.

2. Prior Third Party Information. I will not bring to Intel, disclose to anyone at or outside of Intel as part of my Intel work, or use as

part of my Intel work, any proprietary or confidential information of any former employer or third

party without their written authorization.

3. Confidential Information and Intel Property. During and after my Intel employment, I will hold in strict confidence and not disclose or use any

Confidential Information connected with Intel business or the business of any of Intel’s suppliers,

customers, employees, or contractors unless (i) such disclosure or use is required in connection

with my Intel work, (ii) such information becomes lawfully and publicly known outside Intel, or (iii) an

Intel officer expressly authorizes such disclosure or use in advance and in writing. For purposes of

this Agreement, Confidential Information includes, without limitation: technical information (e.g.

roadmaps, schematics, source code, specifications), business information (e.g. product information,

marketing strategies, markets, sales, customers, customer lists or phone books), personnel

information (e.g. organizational charts, employee lists, skill sets, employee health information,

names, phone numbers, email addresses, personnel files, employee compensation except where

the disclosure of such personnel information is permissible under local labor law such as the right of

employees to discuss compensation and working conditions under the US National Labor Relations

Act), and other non-public Intel data and information of a similar nature. I understand and agree that

all Confidential Information that I acquire in connection with my Intel employment is Intel’s exclusive

property. I agree to return to Intel all of its Confidential Information (hard or soft copies; originals

and copies) as well as all devices and equipment belonging to Intel (including computers, handheld

electronic devices, telephone equipment and other electronic devices) either at the termination of

my Intel employment or upon Intel’s request. I agree that any violation of this provision will result in

immediate and irreparable injuries and harm to Intel, and that Intel shall have the option of pursuing

all available legal and equitable remedies, including injunctive relief and specific performance.

4. Ownership of Proprietary Developments. Except as provided in the next sentence, I agree that all trade secrets, copyrights, mask works,

trademarks, inventions (including service inventions), discoveries, designs, formulae, processes,

methods, manufacturing techniques, improvements, ideas, copyrightable works, and other

intellectual property which I create, invent or discover alone or with others during my Intel

employment, (collectively “Proprietary Developments”) are Intel’s sole property from the moment of

their creation, invention or discovery. This shall not apply to an invention that I develop entirely on

my own time without using Intel equipment, supplies, facilities, or trade secret information, except

for those inventions that either: (1) relate at the time of conception or reduction to practice of the

invention to Intel business, or actual or demonstrably anticipated research or development of Intel;

or (2) result from any work performed by me for Intel. I agree that Intel has and shall always have

sole legal and equitable title to all Proprietary Developments. Further, I have no right to compensation for such Proprietary Developments unless

otherwise provided for by applicable law. I agree to promptly disclose Proprietary Developments to Intel, and

to the full extent allowed by law, but only to the extent not already owned by Intel pursuant to this

Agreement and applicable law, hereby assign to Intel all rights in the Proprietary Developments. I

agree that during and after my employment with Intel I will provide all assistance that Intel

reasonably requests to secure or enforce its rights throughout the world with respect to Proprietary

Developments, including signing all necessary documents to secure or memorialize those rights. If I

fail or refuse to sign documents necessary to secure or enforce Intel’s rights, or if Intel cannot

locate me through the exercise of reasonable diligence, I irrevocably appoint Intel or its designee as

my attorney to sign such documents in my name. I waive any rights that I may have in any

Proprietary Developments and, to the extent that such waiver is ineffective under applicable law

until a Proprietary Development is created, invented or discovered, I agree to waive such rights

immediately upon the creation, invention or discovery of such Proprietary Development.

5. Licensed and Non-Licensed Preexisting Employee Intellectual Property. As used in this Agreement “Preexisting Employee Intellectual Property” means intellectual property

that I created prior to my employment with Intel.

I have specifically listed in Appendix A all Preexisting Employee Intellectual Property that I, in whole

or in part, own or control, or have the right to license and intend to exclude from licensing to Intel

(“Identified Employee Controlled Intellectual Property”).

I agree that I will not use or disclose during my employment any Identified Employee Controlled

Intellectual

Property without the prior written consent of Intel. If I disclose or use any Identified Employee

Controlled Intellectual Property without the prior written consent of Intel, I automatically and

immediately grant Intel a nonexclusive, nontransferable (except within Intel), perpetual, irrevocable,

royalty-free, world-wide license to all of the Identified Employee Controlled Intellectual Property

disclosed or used with the right to sublicense, to make, have made, use, sell, offer to sell, import,

reproduce, have reproduced, prepare derivative works of, distribute, and otherwise dispose of, any

product or document, under all patents, trade secrets, copyrights and copyrightable works, mask

works, trademarks, inventions, discoveries, designs, formulae, processes, methods, manufacturing

techniques, improvements, and ideas.

I have also listed in Appendix A all Preexisting Employee Intellectual Property in which I have an

economic interest (but do not own or control) and for which I do not have the right to grant a license

to Intel.

For the avoidance of doubt, I agree that any Preexisting Employee Intellectual Property that I, in

whole or in part, own, control or have the right to license and that is neither Identified Employee

Controlled Intellectual Property nor identified in Appendix A prior to my employment in sufficient

detail to Intel to identify its subject matter is licensed to Intel in the same manner and scope as

disclosed or used Identified Employee Intellectual Property.

I agree that if I fail to make any required disclosure or breach any term of Sections 4 and 5, any

applicable limitations periods shall be tolled and shall not run as to any claim, right, or cause of

action Intel may have relating to such disclosure or breach that would have been discovered had

the required disclosure been made, until such time as Intel obtains actual knowledge of the facts

giving rise to such claim. Nothing contained in this Section shall limit other remedies otherwise

available in law or in equity to Intel.

6. Non-solicitation and Misappropriation of Intel Trade Secrets. Intel’s Confidential Information includes confidential and private information relating to other

employees and customers. Additionally, Intel has a legitimate business interest in its continuing

employment and customer relationships and in protecting those relationships from unlawful

interference. Accordingly, I agree that for twelve (12) months after my employment ends, I will not

solicit, directly or indirectly, any employee to leave his/her employment with Intel. This applies to

any employees that were employed with Intel as of my separation date from the company and with

whom I had business contact or about whom I had access to Confidential Information during my

previous two years of employment with Intel prior to my separation. I further agree that I shall not

use or disclose Intel Confidential Information on behalf of myself or to aid any third party to target,

identify, and/or solicit Intel customers or Intel employees to leave Intel employment and/or

misappropriate Intel trade secrets. I agree that any violation of this provision will result in

immediate and irreparable injuries and harm to Intel, and that Intel shall have the option of pursuing

all available legal or equitable remedies, including injunctive relief and specific performance. I

understand that nothing in this Agreement prohibits me from disclosing my compensation

information to third parties in accordance with applicable law.

7. Computer Communications Are Not Private.

I acknowledge that use of Intel’s computer systems is not private or confidential. I understand and

consent to Intel’s right to review any communications to or from my work computer, pager, phone or

other electronic device and all computer information, including any password-protected employee

communications, in accordance with applicable law.

8. At-will Employment (U.S. only) I acknowledge that my employment with Intel is “at-will” which means that both Intel and I have the

right to terminate my employment at any time, with or without advance notice and with or without

cause. I understand that if I become employed by an Intel entity outside the U.S., local employment

and termination law will apply if inconsistent with this Agreement.

9. Miscellaneous. I understand that if Intel Corporation is not my employer, Intel Corporation is signing this Agreement

as agent for the Intel Corporation subsidiary, affiliate or successor that is my employer. The

Agreement’s terms and conditions are severable. If any part of this Agreement is found or held to

be unenforceable in any jurisdiction in which this Agreement is being performed, such provision

shall be enforced to the greatest extent permitted by law, and the remainder of this Agreement and

such provision as applied to other persons, places or circumstances shall remain in full force and

effect. This Agreement: (a) survives my employment with Intel; (b) inures to the benefit of successors and assigns of Intel; and (c) is binding upon my heirs,

assigns, and legal representatives. I am not a party to any other agreement which will interfere with

my full compliance with this Agreement, except as I have specifically identified in this Agreement.

For U.S. employees, only a written agreement, signed by the Vice-President, General Manager of

Human Resources can change the “at will” nature of your employment. The remainder of this

Agreement may not be modified or amended except in writing, signed by the parties. Only the Vice

President, General Manager of Human Resources for Intel Corporation, or the General Counsel of

Intel Corporation, or their delegate, has the authority to sign an Agreement modifying the remainder

of this Agreement on behalf of Intel. This Agreement is effective the first day of my employment with

Intel, and supersedes any prior employee agreement signed by me with Intel, relating to this subject

matter. I have carefully read all of the provisions of this Agreement and I understand and will fully

and faithfully comply with all provisions.

Intel Corporation

Steve Rodgers, Signature General Counsel

Employee

__________________________________/___________________ Printed Name & WWID # (please print clearly)

_____________________________

Signature Date

Intel updated Rev. 1/2016

New Employee Orientation Certification

I, ______________________________, acknowledge receipt of the Intel Code of

Conduct, Information Security Business Code of Conduct and other employee

materials. In addition to these documents, I understand that the Intel Employment

Guidelines provide a framework for workplace conduct and expectations. The Intel

Employment Guidelines cover:

About the Intel Employment Guidelines: Equal Employment Opportunity and

Important Information Diversity

Alcohol and Drug-Free Workplace

Non-Fraternization Anti-harassment Open Door

Attendance at Work

Progressive Discipline Conducting Outside Business Security and

Confidential Information Electronic Communications Solicitation, Distribution and Information-Posting

Employee Records and Information Requests Workplace Behavior/Discipline and Discharge

Employment at Will Workplace Threats and Violence

I understand that I am expected to read and comply with the Intel Employment Guidelines

which can be found on Circuit (Intel’s internal website) under the My Life & Career Tab / My

Career / Intel Employment Guidelines. I acknowledge my obligation to review the Intel

Employment Guidelines within the first three weeks of my employment.

I understand and agree that nothing in the Intel Employment Guidelines, Code of Conduct,

Information Security Business Code of Conduct or other policies create an employment

contract or other express contractual obligations on the part of Intel. I also understand

that Intel reserves the right to add, modify, or delete provisions set out in these policies

and guidelines at any time without advance notice. I understand and agree that my

employment is at will which means that either Intel or I have the right to terminate my

employment at any time, with or without advance notice and with or without cause. Only

a written agreement, signed by the Vice-President and Director of Human Resources, can

change the at-will nature of my employment.

I certify that I have read and understand the above.

_____________________________ _______________________________ ________________

__________________

PRINTED NAME EMPLOYEE SIGNATURE WORLDWIDE ID DATE Intel updated Rev 11/2014

The Intel Retirement Plans

Prior Service Credit Questionnaire

New employees who have previously worked at an Intel Subsidiary in a contingent worker assignment as

an employee of a temporary employment or service agency may be eligible for Prior Service Credit

under the Intel Retirement Plans. Intel Subsidiaries include (but not limited to) McAfee, WindRiver,

Havok.

This questionnaire should be used for prior service only.

If you cannot answer “Yes” to ALL of the below questions, you are not eligible for Prior

Service Credit and should not complete or submit this questionnaire.

Yes No I have performed service for an Intel Subsidiary while working as an employee of another

company e.g. employment or temporary agency (i.e.:

Kelly Services, etc). NOTE:

- Independent contractors should answer

“No”

- Individuals employed directly for a company acquired by Intel should answer “No”

Yes No While working as an employee of another company (contingent worker), I reported to and was directly managed in my daily activities by an Intel Subsidiary employee during the entire 365 day period.

Yes No

I worked for an Intel Subsidiary service agency or

supplier for a minimum of 12 consecutive

(unbroken) months within the five years

prior to my most current Intel Hire or Rehire

date

If you answered “Yes” to ALL of the above questions, please complete remaining

information below, sign, scan and send this form to: [email protected]

Your answers will help us verify (if required, you can provide proof of your eligibility information by W2

or other means) and set up your eligibility for Prior Service Credit under the Intel Retirement Plans. Prior

Service Credit will be used to determine when you are eligible to participate in the Plans, and when

future Intel contributions may be made and will vest on your behalf.

Prior Service Credit Employee Eligibility Information

Please provide the following information regarding your employment with the temporary agency or

service agency.

If you have worked for more than one agency, please use the back of this form for additional agency

information.

Incomplete forms will not be processed

Agency Name: _____________________________________________ (example: Kelly Services)

Address: ______________________________________________________________ (street, city,

state, zip) Area Code and Phone #: _____________ Agency Contact Name: __________________________

Agency Employment Dates: From __ __ - __ __ - __ __ to __ __ - __ __- __ __

*Dates must include full MM-DD-YY or they will not be processed

Description of service you provided while an employee of this agency:

_________________________________________________________________________ Name of

Intel Subsidiary employee who managed you: ___________________________ Describe how you

were managed by the Intel Subsidiary employee:

____________________________________________________________________________

Signature - By signing below you are certifying that the above information is correct and if required,

you can provide proof of your eligibility information by W2 or other means.

Print Name: ______________________ Intel Mailstop ______________________

WWID____________________

Employee’s Signature _________________________________________________

Date_____________________

Additional Prior Service Credit Eligibility Information







_________________________________________________________________________ Name of



_________________________________________________________________________________

_________________________________




WWID____________________


Date_____________________

Additional Prior Service Credit Eligibility Information







_________________________________________________________________________ Name of



_________________________________________________________________________________

_________________________________




WWID____________________


Date_____________________

Welcome to Intel, Part of getting started at Intel is to make critical benefits decisions for you and your family. If you are eligible, you are automatically enrolled in the benefits described under Default Coverage below from your date of hire (except for Interns who default to no coverage). No action is required by you unless you wish to select different plan options, waive (no coverage) coverage for yourself, or enroll your eligible dependents.

To research your options, costs, or to begin the enrollment process visit the My Health Benefits Web site; from Circuit, search for My Health Benefits or from the Internet at www.intel.com/go/myben.

As a new hire I understand that: √ I must take action within 30 days of my start date to either enroll or waive benefits for myself and any

eligible dependents or I will be defaulted into the coverage described below. The next opportunity to change my benefits will be during annual enrollment or if I experience a change-in-

status event (e.g., marriage, birth of a child). Enrollment for any change-in-status event must be completed within 30 days of the date of the event.

√ I must select the same medical and dental plan for my dependents as I do for myself. √ The coverage I select will take effect back to my hire or rehire date.

I understand that my decision not to take action will result in the Default Coverage below:

√ I will be automatically enrolled in the Default Coverage which is the employee only coverage for medical (Anthem Blue Cross High Deductible Health Plan) at a cost of $0 per month, dental (Delta Dental) at a cost of $2.00 per month and basic vision plan (VSP) for $1.00 per month (except for Interns, who will default to no coverage)

You can change this default coverage by accessing the My Health Benefits Web site within the first 30 days from your hire or rehire date.

√ Short-Term Disability (STD): STD provides financial assistance if I am unable to work due to illness, injury, or pregnancy. NOTE: CA, NJ, NY, RI and HI make enrollment in STD mandatory.

If I live in CA, I will automatically be enrolled in the Intel California Voluntary Short Term Disability Plan (CA-VSTD) at a cost of 0.8% of wages to an annual maximum of $650.00. I understand I will be allowed to change to the CA state disability insurance plan (CA-STD) at a higher cost (1.0% of wages to an annual maximum of $1016.36), but will not be allowed to completely opt out of all plans. NOTE: The CA-VSTD provides richer coverage at a lower cost than the CA-SDI plan.

If I live in HI, I will be automatically enrolled in my state disability plan. I further understand that I will be auto-enrolled in the Intel STD plan as supplement coverage at a combined state STD Plan and Intel STD Plan cost of 0.8% of wages to an annual maximum of $604.68. You can only waive the supplemental

http://www.intel.com/go/myben





default coverage by accessing the My Health Benefits Web site within the first 30 days from your hire or rehire date.

If I live in NJ, I will be automatically enrolled in my state disability plan. I further understand that I will be auto-enrolled in the Intel STD plan as supplement coverage at a combined state STD Plan and Intel STD Plan cost of 0.9% of wages to an annual maximum of $608.46. You can only waive the supplemental default coverage by accessing the My Health Benefits Web site within the first 30 days from your hire or rehire date.

If I live in NY, I will be automatically enrolled in my state disability plan. I further understand that I will be auto-enrolled in the Intel STD plan as supplement coverage at a combined state STD Plan and Intel STD Plan cost of 0.8% of wages to an annual maximum of $600. You can only waive the supplemental default coverage by accessing the My Health Benefits Web site within the first 30 days from your hire or rehire date.

If I live in RI, I will be automatically enrolled in my state disability plan at a cost of 1.2% of wages to an annual maximum of $752.40. You cannot waive this coverage.

If I live in any state not mentioned above, I will be automatically enrolled in the Intel STD plan at a cost of 0.8% of wages to an annual maximum of $600. You can waive this default coverage by accessing the My Health Benefits Web site within the first 30 days from your hire or rehire date.

I understand the cost of medical, dental and disability coverage noted above are 2014 rates and are subject to change. Notice of Special Enrollment Rights If you are waiving enrollment in the Intel Group Health Plan for yourself or your dependents (spouse and children) because of other health insurance coverage, you may in the future be able to enroll yourself and your dependents in the Intel Group Health Plan provided that you request enrollment within 30 days after your other coverage ends. In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependent provided that you request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. Additionally, you may be able to enroll yourself and your dependents in the Intel Group Health Plan under these additional two scenarios:

You or your dependent(s) Medicaid or Children’s Health Insurance Program (“CHIP”) coverage is terminated as a result of

loss of eligibility. You must request this special enrollment for you and your dependent(s) within 60 days of the loss of coverage for Medicaid or CHIP.

You or your dependent(s) become eligible for a premium assistance subsidy* under Medicaid or CHIP. You must request

this special enrollment within 60 days of when eligibility for the premium assistance subsidy is determined.

* Note: States may elect to provide premium assistance subsidies to eligible, low-income children under a qualified employer-sponsored group health plan by reimbursing employees for the difference in cost between the state plan and the employer’s plan. The Health FSA, CIGNA HDHP, and Anthem Blue Cross HDHP are not considered a qualified employer sponsored group health plan. ___________________________ ______________________________ _______________ ___________

PRINTED NAME EMPLOYEE SIGNATURE WWID DATE

NOTE: To begin the enrollment process or to find additional information on program costs, visit the My Health Benefits Web site; from Circuit, search for My Health Benefits or from the Internet at www.intel.com/go/myben. If you have questions about your health benefits, benefit costs or enrolling, contact the Intel Health Benefits Center at (877) GoMyBen (466-9236). For complete information on Intel’s Health and Disability programs visit the Pay, Stock and Benefits Handbook. From Circuit, search for Pay, Stock and Benefits Handbook.

Intel Confidential NEONHBensigform12/4/2013 Intel offers a New Hire Pay & Benefit course to all new hires. This course will provide an overview of the medical, dental, flexible spending accounts, life insurance, disability, stock and retirement benefits offered by Intel. Following your Start Date, if you are interested in attending the course, please visit “Circuit > My Learning> My Learning Tool”. In My Learning Search, type New Hire Pay, select Virtual Classroom (VC) from the drop down menu, check mark Match Exact Phrase and click Search. Refine the search result by clicking Sites, selecting All sites and click Apply. The results will display the available offerings for the class. Click Register in the offering that best suits your calendar. A registration confirmation will show up.

Intel Confidential NEONHBensigform12/4/2013








Important information about medical care if

you have a work-related injury or illness

California law requires that Intel provide and pay for medical treatment if you are injured at work.

This medical care is provided by a Workers’ Compensation physician network called a Medical

Provider Network (MPN).

The following New Hire Notice describes your rights in choosing medical care for work-related

injuries and illnesses. It is your responsibility to read and understand this information. You may

download this document for your reference.

Please note that you may pre-designate your personal physician for work injuries as long as you do

so before sustaining an injury. The criteria for pre-designating your physician are:

• You have previously received care with the physician,

• Your physician is an M.D. or D.O., and

• Your physician agrees to be your primary treating physician in the event of an injury.

If the criteria are not met, medical care will be provided through the MPN. More information about

how to pre-designate is included in the New Hire Notice below which includes a form to complete

to pre-designate a physician. If you chose this option, return the completed form to your local

Occupational Health Office.

California Occupational Health Office Locations

Folsom Santa Clara - Mission

FM2 – 1st Floor In the link between SC9 and SC12

Mon – Fri 8 a.m. – 5 p.m. Mon – Fri 8 a.m. – 5 p.m.

Phone: 916-356-5039 Phone: 408-765-9587

Fax: 916-356-6960 Fax: 408-765-9010

Page 1

Based 2/Quality 2 MPN)

For more information or to report a work-related injury, go to the Health and Wellness Programs

intranet site. To access the Health and Wellness Programs intranet site from Circuit, select the

MPN Identification Number: #2323

Sedgwick/Harbor MPN (Outcomes-

My Life and Career tab, and under the My Health section select the Health and Wellness Programs

link, then select the Report a Workplace Illness or Injury link.

For a list of the Information & Assistance Unit of the California Department of Industrial Relations,

visit the web site: http://www.dir.ca.gov/dwc/ianda.html.

Version espagnole disponible sur demande.

New Hire Notice -- Injuries Caused By Work What does workers’ compensation cover?

You may be entitled to workers' compensation benefits if

you are injured or become ill because of your job. Workers'

compensation covers most work-related physical or mental

injuries and illnesses. An injury or illness can be caused by

one event (such as hurting your back in a fall) or by repeated

exposures such as hurting your wrist from doing the same

motion over and over). Generally, independent contractors,

and volunteers who receive no compensation are not

covered by workers’ compensation benefits.

Benefits:

Workers' compensation benefits include: Medical care,

temporary disability, permanent disability, supplemental

job displacement voucher, and death benefits

Medical Care:

You are entitled to medical care that is reasonably required

to cure or relieve you from the effects of your work-related

injury. Medical care may include doctor visits, hospital

services, physical therapy, lab tests, x-rays, and medicines

that are reasonably necessary to treat your injury.

Providers should never bill you directly for work-related

injuries. There is a limit on some medical services. Your

employer is required to provide you with a claim form

within one business day of learning about your injury. It is

extremely important that you complete the “Employee”

section of the claim form as your employer is required to

authorize medical care within one working day after you file

the form. If additional care is necessary after the initial

treatment, the claims administrator will authorize any care

that is appropriate for your injury, including the referral to

specialists. Your Primary Treating Physician (PTP):

This is the doctor with overall responsibility for treating your

injury or illness. The primary treating physician determines

what type of treatment you need and when you may return

to work. A multispecialty medical group of licensed doctors

and osteopathy can be designated as personal physicians. If

your employer or your employer’s insurer does not have a

Medical Provider Network, you may be able to change your

treating physician to your personal chiropractor or

acupuncturist following a work- related injury or illness by

making a request to the claims administrator. Chiropractors

may not continue as the primary treating physician after 24

http://www.dir.ca.gov/dwc/ianda.html





visits. If specialists, diagnostics, etc. are needed in your case,

this physician will be responsible for making the referrals. If

you name your personal physician before your injury, you

may see him or her for treatment in certain circumstances. Otherwise, your employer has the right to select the

physician who will treat you for the first 30 days. You may

be able to switch to a doctor of your choice after 30 days.

Special rules apply if your employer offers a Health Care

Organization (HCO) or has a medical provider network. You

should receive information from your employer if you are

covered by an HCO or MPN. Contact your employer for

more information.

Treatment by your personal physician:

You may be treated by your personal physician if you notify

your employer prior to your injury. A personal physician

includes a medical group of licensed doctors of

medicine or osteopathy. Please have your physician

complete the attached form and return to your employer. The following requirements must be met:



1. Your employer must offer group health coverage 2. Your personal physician must agree in advance to treat

you for any work injuries or illnesses 3. Your physician

must be your regular physician and surgeon. 4. Your physician has previously directed your medical

treatment and retains your records, including your

medical history.

What happens if your employer disputes your injury?

State law requires employers to authorize medical care

within one working day of receiving a DWC 1 claim form.

Your employer may be liable for as much as $10,000 in

medical care until your claim is accepted or denied.

Medical Provider Networks:

Your employer may be using a MPN, which is a selected

network of health care providers to provide treatment to

workers injured on the job. If your employer is using a MPN,

a MPN notice should be posted next to this poster to explain

how to use the MPN. You can request a copy of this notice

by calling the MPN number below. If you have

predesignated your personal physician prior to your work

injury, then you may receive treatment from your

predesignated doctor. If you have not predesignated

and your employer is using a MPN, you are free to choose

an appropriate provider from the MPN list after the first

medical visit directed by the employer. If you are treating

with a non-MPN doctor for an existing injury, you may be

required to change to a doctor within the MPN. For more

information see the MPN contact information below

Medical Access Assistant for California MPNs:

The Medical Access Assistant, or MAA, has the primary duty

of assisting employees with finding available medical

provider network physicians and scheduling medical

appointments. The MAA shall be available Monday through

Saturday from 7:00 AM – 8:00 PM (Pacific standard time).

The MAA will contact the physician during normal business

hours to schedule your appointment. The MAA does not

have authority to authorize treatment and maintains

different duties than the claims examiner. Sedgwick

Medical Access Assistant:

Phone: 1-87-SEDGWICK or 1-877-334-9425

Current MPN toll free number: 800-625-6588

MPN Website: www.sedgwickproviders.com/campn2

• Select method of search: physician name, address

search, or region search

• Input the state and zip code information • Click “Find Provider”

Current MPN Address: Sedgwick

CMS 10690 White Rock Road

Suite 100

Rancho Cordova, CA 95670 MPN Effective Date: ___10/31/2015_______________

What if my employer has a Medical Provider Network?

Please refer to the posted Complete Employee Notice at

your employer’s location for network details and

requirements. If your employer does not have a Medical Provider Network,

you may be able to change your treating physician to your

personal chiropractor or acupuncturist following a

workrelated injury or illness within 30 days of reporting your

injury. You may use the attached Notice of Personal

Chiropractor or Personal Acupuncturist form to notify your

employer of this change.

Emergency Medical Care:

What if my employer does not have a Medical Provider Network?


If you need emergency care, call 911 for help immediately

from the hospital, ambulance, fire department or police

department.

If you need first aid treatment, contact your employer. If you

have more than a simple first aid injury, you will need to ask

your employer for a claim form.

Temporary Disability (TD) Benefits:

You may be entitled to payments if you lose wages while

recovering. Your temporary disability rate is calculated by

multiplying your average weekly wage by two thirds. The

first 3 days of disability are not payable under California law

unless there is hospitalization at the time of injury or the

disability exceeds 14 days. If your physician returns you to

work on a modified basis, you may be entitled

First Aid:




to wage loss. This is generally calculated by multiplying the

difference between your average weekly wage and your

earnings during modified duties times two thirds. This is

subject to the benefit minimums and maximums set by the

California Legislature. Temporary disability benefits are

payable within 14 days of the date of injury or knowledge of

the injury. Subsequent payments are due every 14 days. For

injuries occurring on or after 1/1/08, no more than 104

weeks of temporary disability are payable within 5 years

from the date of injury. For longer term conditions (hepatitis

B &C, amputations, severe burns, HIV, high velocity eye

injuries, chemical burns to the eyes, pulmonary fibrosis, and

chronic lung disease) no more than 240 weeks within five

years from the date of injury are payable. You may be

eligible for state disability benefits from the Employment

Development Department (EDD) if TD benefits are stopped,

delayed, or denied. There are time limits so contact EDD for

more information.

Permanent Disability (PD) Benefits:

You may be entitled to payments if your physician says your

injury has limited your ability to work. The permanent

disability rate is calculated by multiplying your average

weekly wage by two thirds, subject to statutory minimums

and maximums. The amount of permanent disability or

impairment may depend on your doctor’s opinion, as well

as your age, occupation type of injury and date of injury. If

you have permanent disability or your claims examiner

suspects you have permanent disability, a letter will be sent

to you explaining your benefits, including the estimate or

total value of permanent disability, weekly payment

amount, how the benefit was calculated, and all of your

related rights under the California Labor Code, including

your right to object to the report upon which the

determination is being based. Permanent Disability benefits

are payable within 14 days of the last payment of temporary

disability benefits or after you physician indicates there is

permanent disability. The benefit is payable every fourteen

days. Supplemental Job Displacement Benefit:

You may be entitled to a nontransferable voucher payable

to a state approved school. To qualify, your injury must

result in a permanent impairment and your employer is

unable to offer modified or alternative work within 60 days

of receipt of a report asserting that all medical conditions

have reached maximum medical improvement. If your

employer does not offer a modified or alternate job within 60 days of determination of maximum medical

improvement, you may chose to receive a nontransferable

voucher to use at a state accredited school for

educationrelated retraining or skill replacement. If you

qualify for the supplemental job displacement benefit, your

claims examiner will provide a voucher for up to $6,000.00.

Return to Work Fund

If your injury results in permanent impairment and it is

determined that the amount awarded is disproportionately

low in comparison to your loss of earnings, you may be

entitled to additional compensation. A fund was

established to supplement permanent impairment benefits

under specific circumstances. This fund is administered by

the Division of Workers Compensation. Your examiner can

assist in directing you to the correct resource to determine

eligibility.

Death Benefits:

Death benefits are paid to dependents of a worker who dies

from a work-related injury or illness. The benefit is

calculated and paid in the same manner as temporary

disability. This benefit is paid at a minimum rate of $224 per

week. The death benefit rates are set by state law and the

amount depends upon the number of dependents. If

dependent minor children are involved, death benefits are

payable at least until the youngest child reaches majority

age. Burial expenses are also provided under this benefit.

Report Your Injury:


Report the injury immediately to your supervisor or to:

Employer representative: ______________________

Phone number: ______________________________

Don't delay. There are time limits. If you wait too long, you

may lose your right to benefits. Your employer is MPN Identification Number: #2323


required to provide you a claim form within one working day

after learning about your injury. Within one working day

after you file a claim form, your employer shall authorize the

provision of all treatment, consistent with the applicable

treating guidelines, for your alleged injury and shall be liable

for up to ten thousand dollars ($10,000) in treatment until

the claim is accepted or rejected. Until the date the claim is

accepted or rejected, liability for medical treatment shall be

limited to ten thousand dollars ($ 10,000). If your claim is

denied, you have the right to appeal the decision within one

year of the date of injury.

Discrimination:

It is illegal for your employer to punish or fire you for having

a work injury or illness, for filing a claim, or testifying in

another person's workers' compensation case. If proven,

you may receive lost wages, job reinstatement, increased

benefits, and costs and expenses up to limits set by the

state.



Questions?

If you have questions, see your employer or the

claims examiner who handles workers'

compensation claims for your employer.

Claims Administrator:

Sedgwick Claims Management Services, Inc.

Address: P.O. Box 14154

_______________________

City: Lexington State: __KY_____Zip:

405124154_______

Phone: 925-598-6980

__________________________

The employer is insured for workers’

compensation by: Self Insured ________________________________________

_______


How do I locate information regarding my employer’s

current workers’ compensation carrier?

For information regarding your employer’s workers’ compensation carrier, please visit the below website.

https://www.caworkcompcoverage.com

If the workers’ compensation policy has expired, contact a Labor Commissioner at the Division of Labor Standards

Enforcement - their number can be found in your local White Pages under California State Government, Department of Industrial Relations.

You can get free information from a State Division of Workers' Compensation Information & Assistance Officer.

The nearest Information & Assistance Officer is at:

Please refer to the attached I&A Office directory for the nearest location. Hear recorded information and a list of

local offices by calling toll-free (800) 736-7401. Learn more online: www.dir.ca.gov.

False claims and false denials: Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers' compensation benefits or payments is guilty of a felony and may be fined and imprisoned.

Your employer may not be liable for the payment of workers’ compensation benefits for any injury that arises from your voluntary participation in any off-duty recreational, social, or athletic activity that is not part of your work-related duties. MPN Identification Number: #2323

Sedgwick/Harbor MPN (Outcomes-Based 2/Quality 2 MPN)

PREDESIGNATION OF PERSONAL PHYSICIAN

https://www.caworkcompcoverage.com/




http://www.dir.ca.gov/




In the event you sustain an injury or illness related to your employment, you may be treated for such injury or illness by

your personal medical doctor (M.D.) or doctor of osteopathic medicine (D.O.) if:

You must have group health coverage for non-industrial injuries or illnesses from any source;

The doctor is your regular physician, who shall be either a physician who has limited his or her practice of medicine to

general practice or who is a board-certified or board-eligible internist, pediatrician, obstetrician-gynecologist, or family

practitioner, and has previously directed your medical treatment, and retains your medical records;

Your "personal physician" may be a medical group if it is a single corporation or partnership composed of licensed doctors

of medicine or osteopathy, which operates an integrated multispecialty medical group providing comprehensive medical

services predominantly for non-occupational illnesses and injuries;

Prior to the injury your doctor agrees to treat you for work injuries or illnesses;

Prior to the injury you provided your employer the following in writing: (1) notice that you want your personal doctor to

treat you for a work-related injury or illness, and (2) your personal doctor’s name and business address.

You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic

medicine treat you for a work- related injury or illness and the above requirements are met. Return the completed form to

your site Occupational Health Office.

NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN Employee:

Complete this section.

TO: (name of employer). If I have a work-related injury or illness, I choose to be treated by:

(name of doctor) (M.D., D.O.)

(street address, city, state, ZIP)

(telephone number)

Employee Name (please print): ___________________________________________________________

Employee’s Address: ___________________________________________________________________

Employee’s Signature: ______________________________________________________________ Date: _________

Physician: I agree to this pre-designation:

Signature: _________________________________________________________________________ Date: _________

(physician or designated employee of the physician)

The physician is not required to sign this form, however, if the physician or designated employee of the

physician does not sign, other documentation of the physician’s agreement to be pre-designated will be

required pursuant to Title 8, California Code of Regulations, section 9780.1 (a)(3)

Page 6

Data Protection Authorization for New Hires

Congratulations on your recent internship or employment with Intel. As part of our new hire paperwork, we request

that you read the following authorization and check the appropriate box below.

Some of the information you are submitting to Intel may be considered personal information and governed by data

protection laws. Intel is committed to complying with applicable data protection laws. As a result, we hereby obtain

your authorization to collect, use, store and transfer your personal information to our global employee database

currently located in California, U.S.A. For some specific applications, such as email services, Intel utilizes cloud

computing technology. Intel will not sell or rent your personal information to third parties without your explicit

consent. We do use third party vendors to provide services on behalf of Intel (for a complete list of those vendors

and the services they provide, please contact Intel HR). These vendors have met our requirements for data

protection compliance. Your personal information will be controlled with access limited to those Intel employees or

vendors contracted by Intel who have a business need to access your personal information. Access rights may

include human resources personnel, your managers and their designees, IT, and limited number third party service

providers responsible for administering your benefits. Access to your personal information will include the

following purposes:

1) Management of the internship or employment relationship – demographic information such as home

address, telephone number, email address, or legally required information such as social security number,

national identification number or its equivalent, and country of citizenship, birth date and gender; 2) Training and career development – information pertaining to education, skills, certifications, training

requirements, training history, course completed/needed, performance evaluations/reviews; 3) Program participation - information needed for enrolment and/or administration of special programs

offered by Intel such as benefits, training programs, succession planning, and any other program you

specifically join; 4) Management of IT and Facilities Services to include office, telephone, email, and computer equipment,

services and access rights; 5) Payroll processing - using information such as your salary, bank account details, total deductions,

allowances, etc.; 6) Intel to know where you work, your work hours, and how you spend your work time - using information

such as work location, job title, supervisor, cost center time/absence records etc.; 7) Support for your technical resource needs, including support of your computer and communications

hardware and software, through Intel’s Technical Assistance Center. 8) Participation in core HR processes - using information such as performance rating, merit increase, job

grade, competencies, development plan, general pay awards, training programs, stock, etc.; 9) Participation in Corporate programs such as bonus or commission plans wherever appropriate, allowances

and awards, stock programs, etc.; 10) Inclusion of your work contact details in the worldwide telephone directory and email directory in order to

facilitate internal communications and foster global teamwork;

11) Enablement of you and your family to participate easily in the various benefit programs - using information

such as family members to be covered by insurance, beneficiaries, etc.; 12) Fulfillment of government reporting requirements - using information such as tax information and other

statutory information; 13) Fulfillment of corporate and statutory audits conducted by our third party auditors; 14) Generation of internal reports for headcounts, budgets, workforce planning, training, etc.; 15) Management of the relocation process – using demographic and legally required information, including

basic information on your family members relocating with you; 16) Participation in Intel’s Community website to keep informed of marketing opportunities, newsletters,

Rev 7, 2014

events, special programs, and the ability to communicate with other Intel community members; 17) Inclusion in specific bench marketing and survey activities related to employee productivity and efficiency

in order to increase Intel performance as a company; or 18) For the purpose of Open Door investigations should Intel have “probable cause” to search your email and

laptop due to suspected violations of company policies, including Intel guidelines such as the Electronic

Communications Guidelines, and/or criminal or illegal activities. Intel may also review and disclose your personal information in order to protect Intel and its employees and assets,

including to: (1) safeguard the legal rights, privacy, and safety of Intel or its employees, partners, or contractors; (2)

protect the safety and security of visitors to Intel’s web sites or other properties; (3) investigate and protect against

violations of Intel’s policies, fraud, or other illegal activity or for risk management purposes; (4) respond to inquiries

or requests from law enforcement and other public authorities/government agents; (5) permit Intel to pursue

available legal remedies or limit the damages that we may sustain; (6) enforce our Terms of Service; or (7) comply

with the law or legal process, including data loss prevention laws. Individuals with access rights to your personal information, including third party vendors (as applicable), have

been educated on data privacy laws and the use of personal information, and have signed Confidential

NonDisclosure Agreements holding them accountable for compliance. Locally, the HR Manager has

responsibility for ensuring the protection of all personal information. On a corporate level, the Global Privacy

Office has overall responsibility for data protection compliance. For a copy of Intel’s data privacy principles and/or privacy policies or if you have any privacy-related questions

please refer to www.intel.com/privacy.

Please select one of the boxes below:

I hereby grant my authorization to Intel for the purposes stated above

I do not grant my authorization to Intel for the purposes stated above. I understand I must contact my

Intel recruiter immediately.

_____________________________ Signature

_____________________________ Print Name

_____________________________ Date

Rev 7, 2014

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