© 2008 ADP TotalSource, Inc. FS104

New Hire Booklet

Employee N

ame

Com

pany Code

© 2008 ADP TotalSource, Inc. FS104

EMPLOYER INSTRUCTIONS:California Employers: Please use the California New Hire Booklet located in the StateAppendix of FormSource

Give the following forms to the new employee:

- New Hire booklet

- State withholding certificate for employee’s work-in state (if required)

- Basic Employment Policies Booklet

Collect the following forms from the new employee (confirm that all forms have beencompleted and signed):

- Employee Personal Information (Note: If the new employee does not indicategender or ethnic group on this form, you must fill it in based upon a visual survey.Do not ask the new employee for this information again.)

- Federal Form W-4

- Direct Deposit Authorization (optional)

- Employment Eligibility Verification (I-9) (Section 1 must be completed and signed bythe employee on or before the first day of employment.)

- Consent to Conduct Background Investigation (if required). Check the box next toeach type of background check you want to order and ask the employee to supply theappropriate information

- State Withholding Certificate (if required)

- Basic Employment Policies Acknowledgment form (located at the back of the BasicEmployment Policies booklet)

Complete the Employment Profile (This may be completed in ADP TotalSource’s Online NewHire Application if you are submitting new hire information electronically.)

Complete and sign Section 2 of the I-9 Employment Eligibility Verification form and verifyemployee documents and signature. Federal Law requires you to complete the I-9 by theemployee’s 3rd day of employment. Refer to FormSource for detailed instructions on the I-9 form.

Enter the new employee information online or, if not entering online, you must fax the newhire booklet and all other forms to your payroll representative. Clients who are submittingnew hire information online must only fax the completed I-9 and Basic Employment PoliciesAcknowledgment forms to ADP TotalSource. All new hire information must be enteredonline or received by ADP TotalSource within 2 business days after selecting an individual forhire. We cannot hire an individual without receiving all of the signed forms listed above.

Print out the employee welcome letter which is produced at the end of submitting the newhire information (only if new employee information is submitted online). Insert the letter intothe Welcome Kit and mail or hand deliver to the new employee. Also, for security, separatelysend the new employee the online password letter to allow access to the secured web site.

Note: All new hire paper work must be maintained by your company for at least 4 years fromthe date of the hire or 4 years from termination, whichever is later.

© 2008 ADP TotalSource, Inc. FS104

EMPLOYEE INSTRUCTIONS:Review all information in this booklet

Complete the following forms, including your signature where indicated, andreturn them to your Worksite Employer:

Employee Personal Information

Federal Form W-4

Direct Deposit Authorization (optional)

Employment Eligibility Verification (I-9), Section 1

Consent to Conduct Background Investigation (if required by youremployer)

In addition to the list above, please complete the following forms and returnthem to your Worksite Employer:

State Withholding Certificate (if required by your state)

Basic Employment Policies Acknowledgment Form (the last page in theBasic Employment Policies booklet)

KB-9104 NH

B

© 2008 ADP TotalSource, Inc. FS104

EMPLOYER USE ONLY(PLEASE PRINT CLEARLY)

KB-9105 NH

B Employer D

ata

Employment Profile Information

Title: __________________________________________________________ Division Code: ____________________________________________________

Department ______________________________________________________

New Department #: ________________________________________________

New Department Description: ______________________________________

Job Cost Code #: __________________________________________________

New Job #: ________________________________________________________

Workers’ Compensation Code: ________________________________ Job Description: __________________________________________________

Benefit Class Code: ____________________________________________

Yes No

(If YES, include a Consentto Conduct BackgroundInvestigation Form)

Worksite Employer Name:____________________________________________________________________ Worksite Employer Code: ____________________

EEO Class (Required; Select the job category that most closelyrelates to this position within your organization)

Executive/Senior Level Officials and Managers

First/Mid-Level Officials and Managers

Professionals Craft Workers

Technicians Laborers and Helpers

Sales Worker Operatives

Administrative Support Service Workers

(If a new department# is needed, please create below)

(If a new job# is needed, please create below)

First Name: Middle Name: Last Name:

________________________________________________ _________________________________ ________________________________________________

Social Security No.: Original Hire Date: TotalSource Start Date: File Number: Background Check:(If different) (If not auto-assigned),

_____________________________________ ______________________ __________________________ ____________________

Hour

Week

Compensation:_________________________________ per: Tipped

Hourly Rate 2:_________________________________ Hourly Rate 3:_________________________________(If Used) (If Used)

Pay Frequency: weekly bi-weekly (26 pay periods/yr.) semi-monthly (24 pay periods/yr) monthly

Pay Type: Salary Hourly

Two Weeks

Semi-Monthly

Month

Year

Pay Status: Full-Time Part-Time Regular Temp

Notes to TotalSource ____________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

Signature of authorized representative or worksite employer: ________________________________________________________________________________

Title:________________________________________________________________________________________ Date: ____________________________________

FLSA Status: Exempt Non-Exempt

Employment Class: Assignee Commission Only Intern Non-Paid Owner

Seasonal Substitute Teacher Teacher 10/12 Trainee

Union Employee Other*: ______________________________________ *Call your Payroll Representative

© 2008 ADP TotalSource, Inc. FS104

EMPLOYEE PERSONAL INFORMATION(PLEASE PRINT CLEARLY)

KB-9106 Employee D

ata

Name of Worksite Employer: ________________________________________________________________________________________________________

Employee Name: (First, Middle Initial, Last): ____________________________________________________________________________________________

Social Security Number:_________________________________________ Birth Date: ____________________________________________________

Contact InformationHome AddressStreet 1: ______________________________________________________

Street 2: ______________________________________________________

City: __________________________________________________________

County:________________________________________________________

State:____________________ Zip: ________________________________

Electronic Contact Information

Home Email: __________________________________________________

Business Emai: ________________________________________________ Maiden Name ________________________________________________

Phone

Home Phone: __________________________________________________

Work Phone: __________________________________________________

Cell Phone: ____________________________________________________

Work-in State:__________________________________________________

Emergency Contact InformationContact #1 Contact #2

Name: ________________________________________________________ Name: ________________________________________________________

Home Phone: __________________________________________________ Home Phone: __________________________________________________

Work Phone: __________________________________________________ Work Phone: __________________________________________________

Cell Phone: ____________________________________________________ Cell Phone: ____________________________________________________

Relationship: __________________________________________________ Relationship: __________________________________________________

Notes to TotalSource: ________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

Are you subject to any city or local income taxes? Yes NoIf so, please provide the city and/or locales below:

Lived-in Worked-in

_________________________ _________________________

_________________________ _________________________

_________________________ _________________________

_________________________ _________________________

Gender: Male Female

Marital Status: Single Married

Divorced Widowed

Common-Law

Ethnic Group: Are you Hispanic or Latino? Yes No

If not Hispanic or Latino, please indicate below:White Black or African American

Asian American Indian/Alaska Native

Two or more races Native Hawaiian or other Pacific Islander

Form W-4 (2013)Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes.

Exemption from withholding. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2013 expires February 17, 2014. See Pub. 505, Tax Withholding and Estimated Tax.

Note. If another person can claim you as a dependent on his or her tax return, you cannot claim exemption from withholding if your income exceeds $1,000 and includes more than $350 of unearned income (for example, interest and dividends).

Basic instructions. If you are not exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding allowances based on itemized deductions, certain credits, adjustments to income, or two-earners/multiple jobs situations.

Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.

Head of household. Generally, you can claim head of household filing status on your tax return only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See Pub. 501, Exemptions, Standard Deduction, and Filing Information, for information.

Tax credits. You can take projected tax credits into account in figuring your allowable number of withholding allowances. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below. See Pub. 505 for information on converting your other credits into withholding allowances.

Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you may owe additional tax. If you have pension or annuity

income, see Pub. 505 to find out if you should adjust your withholding on Form W-4 or W-4P.

Two earners or multiple jobs. If you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. See Pub. 505 for details.

Nonresident alien. If you are a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.

Check your withholding. After your Form W-4 takes effect, use Pub. 505 to see how the amount you are having withheld compares to your projected total tax for 2013. See Pub. 505, especially if your earnings exceed $130,000 (Single) or $180,000 (Married).

Future developments. Information about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted at www.irs.gov/w4.

Personal Allowances Worksheet (Keep for your records.)

A Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . . A

B Enter “1” if: { • You are single and have only one job; or

• You are married, have only one job, and your spouse does not work; or . . .

• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.} B

C Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or more

than one job. (Entering “-0-” may help you avoid having too little tax withheld.) . . . . . . . . . . . . . . CD Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . . DE Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . . EF Enter “1” if you have at least $1,900 of child or dependent care expenses for which you plan to claim a credit . . . F

(Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)

G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.

• If your total income will be less than $65,000 ($95,000 if married), enter “2” for each eligible child; then less “1” if you

have three to six eligible children or less “2” if you have seven or more eligible children.

• If your total income will be between $65,000 and $84,000 ($95,000 and $119,000 if married), enter “1” for each eligible child . . . GH Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.) H

For accuracy,

complete all worksheets

that apply. {• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions and Adjustments Worksheet on page 2. • If you are single and have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed $40,000 ($10,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld.

• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.

Separate here and give Form W-4 to your employer. Keep the top part for your records.

Form W-4Department of the Treasury

Internal Revenue Service

Employee's Withholding Allowance Certificate Whether you are entitled to claim a certain number of allowances or exemption from withholding is

subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

OMB No. 1545-0074

20131 Your first name and middle initial Last name

Home address (number and street or rural route)

City or town, state, and ZIP code

2 Your social security number

3 Single Married Married, but withhold at higher Single rate.

Note. If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.

4 If your last name differs from that shown on your social security card,

check here. You must call 1-800-772-1213 for a replacement card.

5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 56 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6 $

7 I claim exemption from withholding for 2013, and I certify that I meet both of the following conditions for exemption.

• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.

If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . 7Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.

Employee’s signature (This form is not valid unless you sign it.) Date

8 Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.) 9 Office code (optional) 10 Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 10220Q Form W-4 (2013)

Form W-4 (2013) Page 2 Deductions and Adjustments Worksheet

Note. Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.

1 Enter an estimate of your 2013 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes, medical expenses in excess of 7.5% of your income, and miscellaneous deductions . . . . . . . . . . . . . . . . . . . . . . . . . 1 $

2 Enter: { $12,200 if married filing jointly or surviving spouse

$8,950 if head of household . . . . . . . . . . .

$6,100 if single or married filing separately} 2 $

3 Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 3 $

4 Enter an estimate of your 2013 adjustments to income and any additional standard deduction (see Pub. 505) 4 $

5 Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to

Withholding Allowances for 2013 Form W-4 worksheet in Pub. 505.) . . . . . . . . . . . . 5 $

6 Enter an estimate of your 2013 nonwage income (such as dividends or interest) . . . . . . . . 6 $

7 Subtract line 6 from line 5. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 7 $

8 Divide the amount on line 7 by $3,900 and enter the result here. Drop any fraction . . . . . . . 89 Enter the number from the Personal Allowances Worksheet, line H, page 1 . . . . . . . . . 9

10 Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet, also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1 10

Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.)

Note. Use this worksheet only if the instructions under line H on page 1 direct you here.

1 Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet) 12 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if

you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more

than “3” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter

“-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet . . . . . . . . . 3Note. If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4 through 9 below to

figure the additional withholding amount necessary to avoid a year-end tax bill.

4 Enter the number from line 2 of this worksheet . . . . . . . . . . 45 Enter the number from line 1 of this worksheet . . . . . . . . . . 56 Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . . 67 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . . 7 $

8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . . 8 $

9 Divide line 8 by the number of pay periods remaining in 2013. For example, divide by 25 if you are paid every two

weeks and you complete this form on a date in January when there are 25 pay periods remaining in 2013. Enter

the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck 9 $

Table 1Married Filing Jointly

If wages from LOWEST

paying job are—

Enter on

line 2 above

$0 - $5,000 0 5,001 - 13,000 1

13,001 - 24,000 224,001 - 26,000 326,001 - 30,000 430,001 - 42,000 542,001 - 48,000 648,001 - 55,000 755,001 - 65,000 865,001 - 75,000 975,001 - 85,000 10

85,001 - 97,000 1197,001 - 110,000 12

110,001 - 120,000 13120,001 - 135,000 14135,001 and over 15

All Others

If wages from LOWEST

paying job are—

Enter on

line 2 above

$0 - $8,000 08,001 - 16,000 1

16,001 - 25,000 225,001 - 30,000 330,001 - 40,000 440,001 - 50,000 550,001 - 70,000 670,001 - 80,000 780,001 - 95,000 895,001 - 120,000 9

120,001 and over 10

Table 2Married Filing Jointly

If wages from HIGHEST

paying job are—Enter on

line 7 above

$0 - $72,000 $590

72,001 - 130,000 980130,001 - 200,000 1,090200,001 - 345,000 1,290345,001 - 385,000 1,370385,001 and over 1,540

All Others

If wages from HIGHEST

paying job are—

Enter on

line 7 above

$0 - $37,000 $59037,001 - 80,000 98080,001 - 175,000 1,090

175,001 - 385,000 1,290385,001 and over 1,540

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person who claims no withholding allowances; providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.

You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section 6103.

The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return.

If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.

DIRECT DEPOSIT AUTHORIZATION

© 2008 ADP TotalSource, Inc. P1-100-0606

I choose to waive Direct Deposit Authorization (Otherwise complete Direct Deposit Authorization information below)

Employees are allowed to set up a maximum of five direct deposit accounts. A maximum of three checking accounts and two saving accounts are allowed.

Worksite Employer: ___________________________________________________________ Worksite Employer Code: __________________________________

Employee Name: _____________________________________________________________ Social Security Number: ____________________________________

Account Type Transit/ABA Number Account Number Full Net Deposit Partial Deposit Amount(Check if partial deposit)

1. _____________________ ______________________ ____________________________ ______________

2. _____________________ ______________________ ____________________________ ______________

3. _____________________ ______________________ ____________________________ ______________

4. _____________________ ______________________ ____________________________ ______________

5. _____________________ ______________________ ____________________________ ______________

Send remainder as a live check.

Authorization Statement:

By signing the Direct Deposit Authorization form below you are agreeing to the following:

- I authorize ADP TotalSource and the bank listed above to deposit my net pay or a portion thereof as indicated into my account each pay date.

- If funds to which I am not entitled are deposited to my account, I authorize ADP TotalSource to direct the bank to return said fundsto ADP TotalSource.

- I understand that my deposit may not be credited to my account until midnight on the pay date indicated on the check voucher.

- I understand that it is my responsibility to ensure that my wages are being deposited correctly into my account each pay date.

- I understand that each new account will go through a pre-notification process that may take two payroll periods to complete.

Employee Signature:___________________________________________________________________ Date: __________________________

Account Number:Your bank account number follows the transit numberon the lower, left corner of the check (see diagram).

Transit Number:A nine-digit number located in the lower,left corner of the check (see diagram).

KB-9107 NH

B Direct D

eposit

© 2008 ADP TotalSource, Inc. FS104

CONSENT TO CONDUCT BACKGROUND INVESTIGATION

1

2

3

4

5

6

7

Worksite Employer: _______________________________________________________ Company Code: ________________________

Applicant Name: _____________________________________________ Other names you have used: __________________________

Date of Birth: ______/ ______/ ______ Social Security Number: ___________________________ Gender: __________ Race:______

Driver’s License Number: _______________________________________________________ State Issued: ________________________

List below all addresses for last SEVEN years starting with most current: (attach additional page if necessary):

Street Address City State Zip County Dates

I understand that, as a condition of my employment, ADP TotalSource, its parent and subsidiary com pa nies, af fil i ates, and Clients,including my worksite employer (collectively “TotalSource”), will use the services of a con sum er re port ing agen cy to verify theinformation I have provided on my employment ap pli ca tion, and may, during my employment if hired, use the services of a consumerreporting agency for purposes of making an employment decision. I understand that my successful completion of a backgroundinvestigation is a material term and condition of employment and if I start work before the investigation is completed, my employmentwill be contingent on the results.I understand the investigation may include obtaining information covering up to (1) the last seven (7) years regarding my work habits,education, general reputation, personal char ac ter is tics, credit history, driving records, mode of living, government-issued licenses,judgment liens, criminal background, references, character, past employment, and (2) the last ten years regarding bankruptcies.I understand such information may be obtained by direct or indirect contact from former em ploy ers, schools, financial institutions,landlords and public agencies and through personal interviews with my neighbors, friends and associates, acquaintances or otherpersons who may have such knowledge. The information requested is required by law enforcement agencies and other entities forpositive identification purposes and will not be used for any other purpose. By checking this box , I authorize you to contact mycurrent employer.In the event personal interviews are conducted, I understand that I have the right to receive notice about the nature and scope of anyinvestigative consumer report within five days after TotalSource receives my request or five days after the investigative consumer reportwas requested, whichever is later, unless a shorter time is required by state law. By checking this box I indicate that I wish to receivefurther disclosure about the nature and scope of any TotalSource request for an investigative consumer report.I also understand that before I am denied employment based on information obtained in the report, I will be provided a copy of thereport and a description in writing of my rights under the Fair Credit Reporting Act.I understand if I disagree with the accuracy of any information in the report, I must notify TotalSource within five business days of myreceipt of the report. If I notify TotalSource within five days of the receipt of the report that I am challenging in for ma tion in the report,TotalSource will not make a final decision on my employment status until after I have had a reasonable opportunity to address thediscrepancy.I hereby consent to this investigation and authorize TotalSource to procure a report on my background from a consumer reportingagency. I authorize ADP TotalSource and its clients to release the results of background checks to each other and to other ADPTotalSource clients for whom I have applied for employment, and release ADP TotalSource and its clients from any and all claimsrelated to the lawful release of this information. I release TotalSource and any and all persons or entities providing information orreports about me from any liability arising out of the requests or release of information. This report will be processed by: ADPScreening and Selection Services - 301 Remington Street - Fort Collins, Colorado 80524 / 800-367-5933.California applicants only: The nature and scope of the investigation sought is as follows: _______________________________. I havethe right to request a copy of my consumer report from the consumer reporting agency by checking this box . The report will besent directly to me by the agency to my most current address listed. I understand I have the right to inspect visually the filesconcerning me maintained by an investigative consumer credit reporting agency during normal business hours and upon reasonable

KB-9113 Background Consent

© 2008 ADP TotalSource, Inc. FS104

For Worksite Employer Use Only

For ADP TotalSource Use Only

Date Form Was Received: _________________ Processed By: ___________________________________________________ Date: ________________

notice. The inspection can be done in person if I appear in person and furnish proper identification; I am entitled to a copy of thefile for a fee not to exceed the actual costs of duplication. I am entitled to be accompanied by one person of my choosing, whoshall furnish reasonable identification. The inspection can also be done via certified mail if I make a written request, with properidentification, for copies to be sent to a specified addressee. I can also request a summary of the information to be provided bytelephone if I make a written request, with proper identification for telephone disclosure, and the toll charge, if any, for thetelephone call is prepaid by or directly charged to me. I further understand that the investigative consumer credit reporting agencyshall provide trained personnel to explain to me any of the information furnished to me; I shall receive from the investigativeconsumer reporting agency a written explanation of any coded information contained in files maintained on me. “Properidentification” as used in this paragraph means information generally deemed sufficient to identify a person, including documentssuch as a valid driver’s license, social security account number, military identification card and credit cards. Massachusetts Applicants only: The specific nature and scope of the investigation involving personal interviews includes:__________________________________. I also understand that before or in the event I am denied employment based, in whole orin part, on information obtained in the report, I will be provided a copy of the report and a description in writing of my applicablestate rights.Minnesota applicants only: I have the right to request a copy of my consumer report from the consumer reporting agency bychecking this box . The report will be sent directly to me by the agency to my most current address listed. I also have the right,upon my direct request to the consumer reporting agency, to obtain a complete an accurate disclosure of the nature and scope ofthe consumer report. The disclosure obtained from the consumer reporting agency must be in writing and mailed or delivered tome within five days after the request for the disclosure was received or the consumer report was requested, whichever is later.New Jersey applicants only: The specific nature and scope of the investigation involving personal interviews includes:__________________________________. Oklahoma applicants only: I have the right to request a copy of my consumer report from the consumer reporting agency bychecking this box . The report will be sent directly to me by the agency to my most current address listed.Washington applicants only: I also understand that before or in the event I am denied employment based, in whole or in part, oninformation obtained in the report, I will be provided a copy of the report and a description in writing of my applicable state rights.

________________________________________________Employee Signature

________________________Date

Driver’s License#:____________________________________________________ State Issued: _______________State: ______________________ State: _________________________________ State: _____________________County Name:_______________________________________________________ State: _____________________

Employer name: _______________________________ City: _____________________________ State: ________Employer name: _______________________________ City: _____________________________ State: ________Employer name: _______________________________ City: _____________________________ State: ________Employer name: _______________________________ City: _____________________________ State: ________

Institution name: _______________________________ City: _____________________________ State: ________Institution name: _______________________________ City: _____________________________ State: ________Institution name: _______________________________ City: _____________________________ State: ________

Sex Offender Registry State(s): ________________________________________ Department of Health & Human Services Check Government Sanctions Registry

Credit CrimLink Motor Vehicle

State Criminal County Criminal Federal Criminal Employment

(Verify applicant consent above)

Education

Government Registries

Return results by email to ______________________________________________ OR Return Results by Fax to # ______________________________

Fax this form to: 866-580-3238 Phone: 866-400-6011, option 1

Position offered: ______________________________________________________