Store# Name (First, Middle, Last) SSN # Date of Birth. City State Zip. Hire Date Position Rate of pay/annual Salary. Select... Rehire.

Transcription

1 Store# Name (First, Middle, Last) SSN # Date of Birth Address Apt/Lot City State Zip Hire Date Position Rate of pay/annual Salary Rehire nmlkj Yes nmlkj No Select... Native American If yes, please list Tribe nmlkj nmlkj Yes No The following are yours to print for your own personal records.

2 A B C D E F G H 1 Your first name and middle initial Last name 2 Your social security number Home address (number and street or rural route) City or town, state and ZIP code 3 Single Married Married but withholding at a higher, Single rate. Note: If married, but legally separated, or spouse in a non resident alien, check the "Single" box. 4 If your last name differs from that shown on your social security card, check here. You must call for a replacement card. 5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 5 6 Additional amount, if any, you want withheld from each paycheck $ 7 I claim exemption from withholding for 2016, and I certify that I meet both of the following conditions for exemption. Last year I had the right to a refund on 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 Under 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

3 Last Name (Family Name) First Name (Given Name) Middle Initial Other Names Used (if any) Address (Street Number and Name) Apt. Number City or Town State Zip Code Date of Birth (mm/dd/yyyy) U.S. Social Security Number Address Telephone Number I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form. I attest, under penalty of perjury, that I am (check on of the following): A citizen of the United States A noncitizen national of the United States (See instructions) A lawful permanent resident (Alien Registration Number/USCIS Number): An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy). Some aliens may write "N/A in this field. (See instructions) For aliens authorized to work, provide your Alien Registration Number/USCIS Number OR For I-94 Admission Number: 1. Alien Registration Number/USCIS Number: OR 2. Form I-94 Admission Number: If you obtained your admission number from CBP in connection with your arrival in the United States, include the following: Foreign Passport Number: Country of Issuance: Some aliens may write "N/A" on the Foreign Passport Number and Country of Issuance fields. (See instructions) Signature of Employee: Date (mm/dd/yyyy):

4 Employee Last Name, First Name and Middle Initial from Section 1: List A Identity and Employment Authorization OR List B Identity AND List C Employment Authorization Document Title: Document Title: Document Title: Issuing Authority: Issuing Authority: Issuing Authority: Document Number: Document Number: Document Number: Expiration Date (if any) (mm/dd/yyyy): Expiration Date (if any)(mm/dd/yyyy): Expiration Date (if any)(mm/dd/yyyy): Document Title: Issuing Authority: Document Number: Expiration Date (if any) (mm/dd/yyyy): Document Title: 3-D Barcode Do Not Write in This Space Issuing Authority: Document Number: Expiration Date (if any) (mm/dd/yyyy):

5 Your name Social security number Street address where you live City or town, state, and ZIP code Country Telephone number If you are under age 40, enter your date of birth (month, day, year) Check here if you received a conditional certification from the state workforce agency (SWA) or a participating local agency for the work opportunity 1 credit. 2 Check here if any of the following statements apply to you. I am a member of a family that has received assistance from Temporary Assistance for Needy Families (TANF) for any 9 months during the past 18 months. I am a veteran and a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (food stamps) for at least a 3-month period during the past 15 months. I was referred here by a rehabilitation agency approved by the state, an employment network under the Ticket to Work program, or the Department of Veterans Affairs. I am at least age 18 but not age 40 or older and I am a member of a family that: a. Received SNAP benefits (food stamps) for the past 6 months; or b. Received SNAP benefits (food stamps) for at least 3 of the past 5 months, but is no longer eligible to receive them During the past year, I was convicted of a felony or released from prison for a felony. I received supplemental security income (SSI) benefits for any month ending during the past 60 days. I am a veteran and I was unemployed for a period or periods totaling at least 4 weeks but less than 6 months during the past year. Check here if you are a veteran and you were unemployed for a period or periods totaling at least 6 months during the past year. Check here if you are a veteran entitled to compensation for a service-connected disability and you were discharged or released from active duty in the U.S. Armed Forces during the past year. Check here if you are a veteran entitled to compensation for a service-connected disability and you were unemployed for a period or periods totaling at least 6 months during the past year. Check here if you are a member of a family that: Received TANF payments for at least the past 18 months; or Received TANF payments for any 18 months beginning after August 5, 1997, and the earliest 18-month period beginning after August 5, 1997, ended during the past 2 years; or Stopped being eligible for TANF payments during the past 2 years because federal or state law limited the maximum time those payments could be made. 7 Check here if you are in a period of unemployment that is at least 27 consecutive weeks and for all or part of that period you received unemployment compensation. Signature -All Applicants Must Sign Under penalties of perjury, I declare that I gave the above information to the employer on or before the day I was offered a job, and it is, to the best of my knowledge, true, correct, and complete. Job applicant's signature Date For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No L Form 8850 (Rev )

6 2016 Employee Benefit Highlight Sheet Eligibility: All full time employees (must work an average of 30 hours per week) Aetna Medical In-Network Summary Deductible: Coinsurance: Maximum out of pocket: Office co-pays: $2,000 Individual $6,000 Family 20% after deductible $6,600 Individual $13,300 Family $25 Primary Care $50 Specialist $50 Urgent Care: Emergency Room: Cost per paycheck: Employee only: Spouse: Employee + Child(ren): Family: $150+20% 9 ½ % of salary 9 ½ % of salary + $ ½ % of salary + $ ½ % of salary + $ To determine your rate, multiply your gross income per paycheck by 9.5% then add the dependent premium shown. (I.e. $7.25 x 30 (hrs) = $ x 2 weeks = $ x 9.5% (.095) = $41.32 cost per pay check for employee only) I elect employee only coverage. (Complete Aetna form) I elect employee plus dependant coverage. (Complete Aetna form) I choose not to enroll in Pamax Management's group medical insurance at this time. I understand this will only be offered one time per year unless I have a qualifying event. Employee Signature Print employee name Date Store This policy meets all of the requirements of the Affordable Care Act. This policy includes the minimum essential benefits and is considered affordable. You will not qualify for government subsidy or tax credits through the Healthcare Marketplace.

7 Social Security Number Position - - Select... First Name Middle Last Name Mailing Address $ Hour Week Commission/Other Month Year New Hire Recalled State of Hire O K City Date started to Work or Recalled Month Day Year State ZIP Code Dependent health insurance available? - Yes No Date of Birth Is this person currently employed with your company? Month Day Year Yes No

8 You may print the company policies for your own record. EMPLOYEE ACKNOWLEDGMENT FORM FOR EMPLOYEE HANDBOOK, CASH HANDLING POLICY, UNIFORM POLICY, COMPUTER USE POLICY, AND ARBITRATION AGREEMENT, AND, IF APPLICABLE ADDITIONAL ADDENDUMS The employee handbook describes important information about the Company, and I understand that it is my responsibility to consult my Manager, District Manager or the Human Resources Department regarding any questions not answered in the handbook. I have entered into my employment relationship with the Company voluntarily and acknowledge that there is no specified length of employment. Accordingly, either the Company or I can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law. Since the information, policies and benefits described herein are necessarily subject to change, I acknowledge that revisions to the handbook may occur, except to the Company's policy of employment-at-will. All such changes will be communicated through official notices, and I understand that revised information may supersede, modify, or eliminate existing policies. Only the President and CEO of the Company has the ability to adopt any revisions to the policies in this handbook. I clearly understand and acknowledge that sexual and other unlawful harassment will not be tolerated in the workplace. Should I be witness or victim to such conduct or behavior I will notify the restaurant manager, district manager, or confidentially to the Human Resources Department immediately upon occurrence. I also understand that my scheduled hours will be dependent upon the business levels and needs of the organization. I understand that I am hired for a part-time position with no guarantee of a set number of hours or set schedule. I acknowledge that this handbook is neither a contract of employment nor a legal document. Furthermore, I have received the following: employee handbook, the cash handling policy, uniform policy, computer use policy, drug policy and the arbitration agreement. I have read the Employee handbook, cash handling policy, uniform policy, computer use policy and arbitration agreement. I understand that it is my responsibility to read and comply with ALL of these policies and any revisions or addendums made to them. I agree to submit and receive information electronically. At any time I may contact the Manager, District Manager or Human Resources Department to request paper copies of all information regarding my employment. Employee Signature Print name Date