NEW HIRE EMPLOYEE INFORMATION FORM

Transcription

1 NEW HIRE EMPLOYEE INFORMATION FORM Employee s Name: Social Security Number: Street Address: Birth Date: Apt / PO Box: City: State: Zip: Primary Phone: Name: Emergency Contact Information Relationship: Contact Phone Number (Daytime): I agree that the information listed above is accurate and correct. I understand and agree that it is my responsibility to complete, sign and submit all applicable re-hire forms including, but not limited to, the W-4, I-9, bank direct deposit, employee handbook receipts and other documents deemed appropriate within the required time in order to continue my employment. Employee Signature: Date: Company Name: Information below to be completed by an Authorized Company Representative Department: Job Title: Start Date: Pay Information: RATE $ Hourly Salary Exempt Salary Non-Exempt Normally Scheduled Hours: to Primary Assigned Shift: First Second Third Average Hours Per Week: Full-Time (30+ hrs/wk) Part-Time (20-29 hrs/wk) On-Call (<20 hrs/wk) Seasonal/Temporary Eligible for benefits after probationary period? Yes No Signature of Authorized Company Representative Date Attach the completed document along with W-4/State tax forms, direct deposit information and I-9 form. Send immediately to ensure timely processing.

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6 Form NJ-W4 (1-10, R-13) 1. SS# Name Address City State Zip State of New Jersey - Division of Taxation Employee s Withholding Allowance Certificate 2. Filing Status: (Check only one box) 1. Single 2. Married/Civil Union Couple Joint 3. Married/Civil Union Partner Separate 4. Head of Household 3. If you have chosen to use the chart from instruction A, enter the appropriate letter here Total number of allowances you are claiming (see instructions) Qualifying Widow(er)/Surviving Civil Union Partner 5. Additional amount you want deducted from each pay $ 6. I claim exemption from withholding of NJ Gross Income Tax and I certify that I have met the conditions in the instructions of the NJ-W4. If you have met the conditions, enter EXEMPT here Under penalties of perjury, I certify that I am entitled to the number of withholding allowances claimed on this certificate or entitled to claim exempt status. Employee s Signature Date Employer s Name and Address Employer Identification Number BASIC INSTRUCTIONS Line 1 Enter your name, address and social security number in the spaces provided. Line 2 Check the box that indicates your filing status. If you checked Box 1 (Single) or Box 3 (Married/Civil Union Partner Separate) you will be withheld at Rate A. Note: If you have checked Box 2 (Married/Civil Union Couple Joint), Box 4 (Head of Household) or Box 5 (Qualifying Widow(er)/Surviving Civil Union Partner) and either your spouse/civil union partner works or you have more than one job or more than one source of income and the combined total of all wages is greater than $50,000, see instruction A below. If you do not complete Line 3, you will be withheld at Rate B. Line 3 If you have chosen to use the wage chart below, enter the appropriate letter. Line 4 Enter the number of allowances you are claiming. Entering a number on this line will decrease the amount of withholding and could result in an underpayment on your return. Line 5 Enter the amount of additional withholdings you want deducted from each pay. Line 6 Enter EXEMPT to indicate that you are exempt from New Jersey Gross Income Tax Withholdings, if you meet one of the following conditions: Your filing status is SINGLE or MARRIED/CIVIL UNION PARTNER SEPARATE and your wages plus your taxable nonwage income will be $10,000 or less for the current year. Your filing status is MARRIED/CIVIL UNION COUPLE JOINT, and your wages combined with your spouse s/civil union partner s wages plus your taxable non wage income will be $20,000 or less for the current year. Your filing status is HEAD OF HOUSEHOLD or QUALIFYING WIDOW(ER)/SURVIVING CIVIL UNION PARTNER and your wages plus your taxable nonwage income will be $20,000 or less for the current year. Your exemption is good for ONE year only. You must complete and submit a form each year certifying you have no New Jersey Gross Income Tax liability and claim exemption from withholding. If you have questions about eligibility, filing status, withholding rates, etc. when completing this form, call the Division of Taxation s Customer Service Center at Instruction A - Wage Chart This chart is designed to increase withholdings on your wages, if these wages will be taxed at a higher rate due to inclusion of other wages or income on your NJ-1040 return. It is not intended to provide withholding for other income or wages. If you need additional withholdings for other income or wages use Line 5 on the NJ-W4. This Wage Chart applies to taxpayers who are married/civil union couple filing jointly, heads of households or qualifying widow(er)/surviving civil union partner. Single individuals or married/civil union partners filing separate returns do not need to use this chart. If you have indicated filing status #2, 4 or 5 on the above NJ-W4 and your taxable income is greater than $50,000, you should strongly consider using the Wage Chart. (See the Rate Tables on the reverse side to estimate your withholding amount). WAGE CHART HOW TO USE THE CHART Total of All 0 10,001 20,001 30,001 40,001 50,001 60,001 70,001 80,001 OVER Other Wages 10,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000 90,000 90,000 1) Find the amount of your wages in the left-hand column. 0 10,000 B B B B B B B B B B 2) Find the amount of the total for all other wages (including your spouse s/civil union partner s wages) along the top row. 3) Follow along the row that contains your wages until you come to the column that contains the other wages. 4) This meeting point indicates the Withholding Table that best reflects your income situation. 5) If you have chosen this method, enter the letter of the withholding rate table on Line 3 of the NJ-W4. NOTE: If your income situation substantially increases (or decreases) in the future, you should resubmit a revised NJ-W4 to your employer. THIS FORM MAY BE REPRODUCED Y O U R W A G E S 10,001 20,000 20,001 30,000 30,001 40,000 40,001 50,000 50,001 60,000 60,001 70,000 70,001 80,000 80,001 90,000 over 90,000 B B B B C C C C C C B B B A A D D D D D B B A A A A A E E E B C A A A A A E E E B C D A A A E E E E B C D A A E E E E E B C D E E E E E E E B C D E E E E E E E B C D E E E E E E E

7 RATE TABLES FOR WAGE CHART The rate tables listed below correspond to the letters in the Wage Chart on the front page. Use these to estimate the amount of withholding that will occur if you choose to use the wage chart. Compare this to your estimated income tax liability for your New Jersey Income Tax return to see if this is the correct amount of withholding that you should have. RATE A WEEKLY PAYROLL PERIOD (Allowance $19.20) ANNUAL PAYROLL PERIOD (Allowance $1,000) $ 0 $ % $ 0 $ 384 $ 673 $ % $ 384 $ 673 $ 769 $ % $ 673 $ 769 $ 1,442 $ % $ 769 $ 1,442 $ % $ 1,442 $ 9,615 $ % $ 9,615 WEEKLY PAYROLL PERIOD (Allowance $19.20) $ 0 $ % $ 0 $ 384 $ 961 $ % $ 384 $ 961 $ 1,346 $ % $ 961 $ 1,346 $ 1,538 $ % $ 1,346 $ 1,538 2,884 $ % $ 1,538 $ 2,884 $ % $ 2,884 $ 9,615 $ % $ 9,615 WEEKLY PAYROLL PERIOD (Allowance $19.20) $ 0 $ % $ 0 $ 384 $ 769 $ % $ 384 $ 769 $ 961 $ % $ 769 $ 961 $ 1,153 $ % $ 961 $ 1,153 $ 2,884 $ % $ 1,153 $ 2,884 $ % $ 2,884 $ 9,615 $ % $ 9,615 WEEKLY PAYROLL PERIOD (Allowance $19.20) $ 0 $ % $ 0 $ 384 $ 769 $ % $ 384 $ 769 $ 961 $ % $ 769 $ 961 $ 1,153 $ % $ 961 $ 1,153 $ 2,884 $ % $ 1,153 $ 2,884 $ % $ 2,884 $ 9,615 $ % $ 9,615 WEEKLY PAYROLL PERIOD (Allowance $19.20) $ 0 $ % $ 0 $ 384 $ 673 $ % $ 384 $ 673 $ 1,923 $ % $ 673 $ 1,923 $ % $ 1,923 $ 9,615 $ % $ 9,615 $ 0 $ 20, % $ 0 $ 20,000 $ 35,000 $ % $ 20,000 $ 35,000 $ 40,000 $ % $ 35,000 $ 40,000 $ 75,000 $ % $ 40,000 $ 75,000 $ 2, % $ 75,000 $ 500,000 $ 32, % $ 500,000 RATE B ANNUAL PAYROLL PERIOD (Allowance $1,000) $ 0 $ 20, % $ 0 $ 20,000 $ 50,000 $ % $ 20,000 $ 50,000 $ 70,000 $ % $ 50,000 $ 70,000 $ 80,000 $ 1, % $ 70,000 $ 80,000 $ 150,000 $ 1, % $ 80,000 $ 150,000 $ 6, % $ 150,000 $ 500,000 $ 30, % $ 500,000 RATE C ANNUAL PAYROLL PERIOD (Allowance $1,000) $ 0 $ 20, % $ 0 $ 20,000 $ 40,000 $ % $ 20,000 $ 40,000 $ 50,000 $ % $ 40,000 $ 50,000 $ 60,000 $ 1, % $ 50,000 $ 60,000 $ 150,000 $ 1, % $ 60,000 $ 150,000 $ 6, % $ 150,000 $ 500,000 $ 29, % $ 500,000 RATE D ANNUAL PAYROLL PERIOD (Allowance $1,000) $ 0 $ 20, % $ 0 $ 20,000 $ 40,000 $ % $ 20,000 $ 40,000 $ 50,000 $ % $ 40,000 $ 50,000 $ 60,000 $ 1, % $ 50,000 $ 60,000 $ 150,000 $ 1, % $ 60,000 $ 150,000 $ 6, % $ 150,000 $ 500,000 $ 29, % $ 500,000 RATE E ANNUAL PAYROLL PERIOD (Allowance $1,000) $ 0 $ 20, % $ 0 $ 20,000 $ 35,000 $ % $ 20,000 $ 35,000 $ 100,000 $ % $ 35,000 $ 100,000 $ 4, % $ 100,000 $ 500,000 $ 30, % $ 500,000

8 DIRECT DEPOSIT AGREEMENT EMPLOYEE NAME: SSN: COMPANY NAME: DEPOSIT #1 Financial Institution: Route/Transit Number: Account Number: Account Type: CHECKING SAVINGS GLOBAL Debit Card Rtg# Deposit Entire Amount Deposit $ Deposit % DEPOSIT #2 Financial Institution: Route/Transit Number: Account Number: Account Type: CHECKING SAVINGS GLOBAL Debit Card Rtg# Deposit Balance Deposit $ Deposit % We cannot process your direct deposit without the supporting documentation from your financial institution. Attach a voided check, letter from your financial institution or other supporting documentation. Do not attach a deposit slip! If you don't provide supporting documentation, you will receive a live check while your direct deposit account information is being verified. I hereby authorize ContinuumHR to initiate automatic deposits to my account(s) at the financial institution(s) named above. Further, I agree not to hold ContinuumHR responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or my financial institution or due to an error on the part of my financial institution in depositing funds to my account. I hereby authorize and request ContinuumHR to deduct from my salary or wages and pay to the named financial institution as indicated above. By signing this form I authorize ContinuumHR to initiate credits and to make adjustments, if necessary, for any entry made in error without express written authorization. I shall look solely to the above named financial institution for any information regarding my account. This agreement will remain in effect until ContinuumHR receives a written notice of cancellation from me or my financial institution, or until I submit a new direct deposit form to the Payroll Department. EMPLOYEE SIGNATURE: DATE: CM/NH 01/2017

9 Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form I-9 OMB No Expires 08/31/2019 START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination. Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.) Last Name (Family Name) First Name (Given Name) Middle Initial Other Last 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 - - Employee's Address Employee's 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 one of the following boxes): 1. A citizen of the United States 2. A noncitizen national of the United States (See instructions) 3. A lawful permanent resident (Alien Registration Number/USCIS Number): 4. An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy): Some aliens may write "N/A" in the expiration date field. (See instructions) Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number. QR Code - Section 1 Do Not Write In This Space 1. Alien Registration Number/USCIS Number: OR 2. Form I-94 Admission Number: OR 3. Foreign Passport Number: Country of Issuance: Signature of Employee Today's Date (mm/dd/yyyy) Preparer and/or Translator Certification (check one): I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1. (Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.) I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct. Signature of Preparer or Translator Today's Date (mm/dd/yyyy) Last Name (Family Name) First Name (Given Name) Address (Street Number and Name) City or Town State ZIP Code Employer Completes Next Page Form I-9 07/17/17 N Page 1 of 3

10 Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form I-9 OMB No Expires 08/31/2019 Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.") Employee Info from Section 1 Last Name (Family Name) First Name (Given Name) M.I. Citizenship/Immigration Status List A OR List B AND List C Identity and Employment Authorization Identity Employment Authorization Document Title Document Title Document Title Issuing Authority Document Number Issuing Authority Document Number Issuing Authority 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 Additional Information QR Code - Sections 2 & 3 Do Not Write In This Space Expiration Date (if any)(mm/dd/yyyy) Document Title Issuing Authority Document Number Expiration Date (if any)(mm/dd/yyyy) Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States. The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions) Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Title of Employer or Authorized Representative Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name Employer's Business or Organization Address (Street Number and Name) City or Town State ZIP Code Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.) A. New Name (if applicable) B. Date of Rehire (if applicable) Last Name (Family Name) First Name (Given Name) Middle Initial Date (mm/dd/yyyy) C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below. Document Title Document Number Expiration Date (if any) (mm/dd/yyyy) I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative Form I-9 07/17/17 N Page 2 of 3

11 LISTS OF ACCEPTABLE DOCUMENTS All documents must be UNEXPIRED Employees may present one selection from List A or a combination of one selection from List B and one selection from List C. LIST A Documents that Establish Both Identity and Employment Authorization LIST B LIST C Documents that Establish Employment Authorization OR Documents that Establish Identity AND 1. U.S. Passport or U.S. Passport Card 2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551) 3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machinereadable immigrant visa 4. Employment Authorization Document that contains a photograph (Form I-766) 5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status: a. Foreign passport; and b. Form I-94 or Form I-94A that has the following: (1) The same name as the passport; and (2) An endorsement of the alien's nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form. 6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI 1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address 2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address 3. School ID card with a photograph 4. Voter's registration card 5. U.S. Military card or draft record 6. Military dependent's ID card 7. U.S. Coast Guard Merchant Mariner Card 8. Native American tribal document 9. Driver's license issued by a Canadian government authority For persons under age 18 who are unable to present a document listed above: 10. School record or report card 11. Clinic, doctor, or hospital record 12. Day-care or nursery school record 1. A Social Security Account Number card, unless the card includes one of the following restrictions: (1) NOT VALID FOR EMPLOYMENT (2) VALID FOR WORK ONLY WITH INS AUTHORIZATION (3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION 2. Certification of report of birth issued by the Department of State (Forms DS-1350, FS-545, FS-240) 3. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal 4. Native American tribal document 5. U.S. Citizen ID Card (Form I-197) 6. Identification Card for Use of Resident Citizen in the United States (Form I-179) 7. Employment authorization document issued by the Department of Homeland Security Examples of many of these documents appear in Part 13 of the Handbook for Employers (M-274). Refer to the instructions for more information about acceptable receipts. Form I-9 07/17/17 N Page 3 of 3

12 IF YOU HAVE THE RIGHT TO WORK Don t let anyone take it away. There are laws to protect you from discrimination in the workplace. You should know that In most cases, employers cannot deny you a job or fire you because of your national origin or citizenship status or refuse to accept your legally acceptable documents. Employers cannot reject documents because they have a future expiration date. Employers cannot terminate you because of E-Verify without giving you an opportunity to resolve the problem. Contact IER For assistance in your own language Phone: TTY: us IER@usdoj.gov Or write to U.S. Department of Justice CRT Immigrant and Employee Rights NYA 950 Pennsylvania Ave., NW Washington, DC If any of these things happen to you, contact the Immigrant and Employee Rights Section (IER). In most cases, employers cannot require you to be a U.S. citizen or a lawful permanent resident. Immigrant and Employee Rights Section U.S. Department of Justice, Civil Rights Division

13 SI USTED TIENE DERECHO A TRABAJAR No deje que nadie se lo quite. Existen leyes que lo protegen contra la discriminación en el trabajo. Usted debe saber que En la mayoría de los casos, los empleadores no pueden negarle un empleo o despedirlo debido a su nacionalidad de origen o estatus de ciudadanía, ni tampoco negarse a aceptar sus documentos válidos y legales. Los empleadores no pueden rechazar documentos porque tengan una fecha de vencimiento futura. Los empleadores no pueden despedirlo debido a E-Verify sin darle una oportunidad de resolver el problema Comuníquese con la IER Para ayuda en su propio idioma: Teléfono: TTY: Mándenos un correo: IER@usdoj.gov O escríbanos a: U.S. Department of Justice CRT Immigrant and Employee Rights NYA 950 Pennsylvania Ave., NW Washington, DC Si alguna de estas cosas le ha sucedido, comuníquese con la Sección de Derechos de Inmigrantes y Empleados (IER, por sus siglas en inglés) En la mayoría de los casos, los empleadores no pueden exigir que usted sea ciudadano estadounidense o residente legal permanente. Sección de Derechos de Inmigrantes y Empleados Departamento de Justica de los EE. UU., División de Derechos Civiles

14 Acknowledgements of Co-Employment Relationship EMPLOYEE ACKNOWLEDGEMENTS & AGREEMENTS I acknowledge and agree that 1) I have been hired as an at-will employee of ContinuumHR which is an employee leasing company, 2) there is no contract of employment which exists between me and the client to which I have been assigned (hereafter my company ); and 3) there is no contract of employment between ContinuumHR and me; and 4) ContinuumHR has no liability with regard to any employment agreement. I further understand and agree that my company, ContinuumHR or I can terminate our employment relationship at any time as I am an at-will employee. I also agree that while I am a leased employee of ContinuumHR, if ContinuumHR does not receive payment from my company for services which I perform as a leased employee, ContinuumHR will still pay me the applicable minimum wage (or the legally required minimum salary) for any such pay period, and I agree to this method of compensation. I understand and agree that ContinuumHR has no obligation to pay me any other compensation or benefit unless ContinuumHR has specifically, in a written agreement with me, adopted the company s obligation to pay me such compensation or benefit. I understand that my company at all times remains obligated to pay me my regular hourly rate of pay if I am a non-exempt employee and to pay me my full salary if I am an exempt employee even if ContinuumHR is not paid by my company. I understand and agree that ContinuumHR does not assume responsibility for payment of bonuses, commissions, severance pay, deferred compensation, profit sharing, vacation, sick or other paid time off pay, or for any other payment where payment for such items has not yet been received by ContinuumHR from my company. I have been informed and I agree that if my assignment with my company or any ContinuumHR client to which I am assigned ends for any reason, I must report back to ContinuumHR within seventy two (72) hours for possible reassignment and that unemployment benefits may be denied if I fail to do so. Employment-At-Will Acknowledgement I acknowledge and agree that my employment with ContinuumHR is that of an employee-at-will and as such is entered into voluntarily. What this means is that my company, ContinuumHR and I are free to end the employment relationship at any time, for any reason, with or without cause or advance notice. I further understand and agree that the employment-at-will status with ContinuumHR may be altered only with the written authorization of the President of ContinuumHR. No one other than the President of ContinuumHR has the authority to bind ContinuumHR to any employment contract for any specified period of time with any employee. If the contractual co-employment relationship between ContinuumHR and my company ends, I will no longer be a co-employee of ContinuumHR, however my relationship with my company will not change because of the termination of the co-employment agreement. Employee Policies Agreement I understand and agree that the Employee Policies describe important information about ContinuumHR and my company. ContinuumHR and my company have the sole discretion to alter these policies from time to time, with or without prior notice. ContinuumHR reserves the right to revise, supplement and rescind or deviate from any policy or provision of the handbook from time to time, with or without notice, as its sole and absolute discretion consistent with all applicable federal and state laws. I also understand that the revisions to these policies may supersede or eliminate existing policies and that such changes will be communicated through official notices when possible. While every attempt has been made to ensure that these policies are consistent with federal, state and local laws, if any questions occur, the policy will be enforced consistent with the applicable law. These policies are not a legal document or an employment contract and may be revised with or without notice. None of these Employee Policies or any individual policies, related practices or guidelines are to be construed as any guarantee of employment, employment contract, or part of any employment contract. I agree and I have received the Employee Policies. I further understand and agree that it is my responsibility to read the Employee Policies and any subsequent additions or revisions and to abide by the rules, policies and standards set forth in the book. The Employee Policies contains representative summary information about employment policies and practices and not all of the ContinuumHR policies are set forth in this book. Nothing in these Employee Policies alters the fact that all employee of ContinuumHR are employed for an indefinite period and that such employment may be terminated at any time, with or without cause or notice, at the will of either the employee or the Employer. CM NH/0715 Employee Acknowledgements and Agreements 1

15 Prohibition Against Discrimination & Harassment Agreement I also agree that is at any time during my employment I am subjected to any type of discrimination because of race, sex, age, religion, color, retaliation, national origin, handicap, disability or marital status, or if I am subjected to any type of harassment including sexual harassment; I will immediately contact an appropriate person of my company, the president or owner of the company and/or my supervisor. I understand and agree that my company and ContinuumHR are responsible for investigating my complaint and taking appropriate action. I further acknowledge and agree that ContinuumHR does not have actual control over my workplace and as such, is not in a position to end or remediate any discrimination, harassment, or retaliation which may be occurring. The responsibility to end such inappropriate conduct rests with my company. Problem/Complaint Resolution Acknowledgement I understand and agree that I have an affirmative obligation to report any workplace harassment or discrimination to my supervisor or my company management staff or a member of the ContinuumHR Human Resources team. ContinuumHR and my company will listen to my problem or concern, investigate it and to the extent possible, settle the matter. I understand that not all matters will be resolved to my satisfaction; however, decisions will be communicated to me in a timely manner. I further agree that the decision of the president of my company and, where applicable, ContinuumHR is final. Complaints will be kept confidential as possible, consistent with the conduct of a full and fair investigation. I also understand that violating confidentiality may be subject to immediate discipline. I further acknowledge that the registering of a valid complaint will no way be used against me, nor will it have an adverse impact on my employment status, unless such accusation is shown to be intentionally false. Safety Rules Agreement I agree to obey the safety rules and to exercise caution in all work activities. In addition, I will comply with all occupational safety and health standards and regulations established by the Occupational Safety and Health Act and state and local regulations. I will immediately report any unsafe condition to the appropriate supervisor and/or ContinuumHR Human Resources professional. I understand that violating safety standards, causing hazardous or dangerous situations, or failing to report or where appropriate, remedy such situations, may be considered sufficient cause for disciplinary action, up to an including suspension or termination of employment. Workers Compensation/On-the Job Injury or Illness Acknowledgement In recognition of the fact that any work related injuries which might be sustained by me are covered by state workers compensation statutes, and to avoid the circumvention of such state statutes which may result from suits against the customers or clients of ContinuumHR or against ContinuumHR based on the same injury or injuries and to the extent permitted by law. I hereby waive and forever release any rights I might have to make claims or bring suit against any client or customer of ContinuumHR or against ContinuumHR for damages based upon injuries which are covered under such workers compensation statutes. I also agree to comply with any drug testing policy which my company or ContinuumHR may adopt, and I specifically agree to post-accident drug testing in any situation where it is allowed by law. I understand and agree that is I am accepted as a leased employee of ContinuumHR, I am expressly prohibited from performing any work outside the state in which I currently reside in, for any client during my status as a leased employee except as may be allowed in writing by ContinuumHR and ContinuumHR s workers compensation carrier. I understand that I will not be a leased employee of ContinuumHR and will not be provided workers compensation benefits through ContinuumHR or ContinuumHR s workers compensation carrier. My leased employment with ContinuumHR will be considered immediately terminated upon commencement of my trip outside of my current state to perform work for a client where prior written approval has not been received from ContinuumHR and its workers compensation carrier. Agreement I have read, understand and agree to all the provisions contained in this Employment Acknowledgements and Agreements. I understand and agree to all terms and conditions herein stated as a condition of my employment. I hereby certify that all the information given on this document or any supporting documents is true and correct, and I understand that any misrepresentations of this information may result in immediate termination of employment. Print Name Employee Signature Date CM NH/0715 Employee Acknowledgements and Agreements 2

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