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1 Department of Homeland Security U.S. Citizenship and Immigration Services OMB No ; Expires 08/31/12 Form I-9, Employment Eligibility Verification Read instructions carefully before completing this form. The instructions must be available during completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documents have a future expiration date may also constitute illegal discrimination. Section 1. Employee Information and Verification (To be completed and signed by employee at the time employment begins.) Print Name: Last First Middle Initial Maiden Name Address (Street Name and Number) Apt. # Date of Birth (month/day/year) City State Zip Code Social Security # 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. Employee's Signature I attest, under penalty of perjury, that I am (check one of the following): A citizen of the United States A noncitizen national of the United States (see instructions) A lawful permanent resident (Alien #) An alien authorized to work (Alien # or Admission #) until (expiration date, if applicable - month/day/year) Date (month/day/year) Preparer and/or Translator Certification (To be completed and signed if Section 1 is prepared by a person other than the employee.) I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct. Preparer's/Translator's Signature Print Name Address (Street Name and Number, City, State, Zip Code) Date (month/day/year) Section 2. Employer Review and Verification (To be completed and signed by employer. Examine one document from List A OR examine one document from List B and one from List C, as listed on the reverse of this form, and record the title, number, and expiration date, if any, of the document(s).) List A OR List B AND List C Document title: Issuing authority: Document #: Expiration Date (if any): Document #: Expiration Date (if any): CERTIFICATION: I attest, under penalty of perjury, that I have examined the document(s) presented by the above-named employee, that the above-listed document(s) appear to be genuine and to relate to the employee named, that the employee began employment on (month/day/year) and that to the best of my knowledge the employee is authorized to work in the United States. (State employment agencies may omit the date the employee began employment.) Signature of Employer or Authorized Representative Print Name Title Business or Organization Name and Address (Street Name and Number, City, State, Zip Code) Date (month/day/year) Section 3. Updating and Reverification (To be completed and signed by employer.) A. New Name (if applicable) B. Date of Rehire (month/day/year) (if applicable) C. If employee's previous grant of work authorization has expired, provide the information below for the document that establishes current employment authorization. Document Title: Document #: Expiration Date (if any): l 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) l have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative Date (month/day/year) Form I-9 (Rev. 08/07/09) Y Page 4

2 2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551) LISTS OF ACCEPTABLE DOCUMENTS All documents must be unexpired LIST A LIST B LIST C Documents that Establish Both Identity and Employment Authorization 1. U.S. Passport or U.S. Passport Card 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. In the case of a nonimmigrant alien authorized to work for a specific employer incident to status, a foreign passport with Form I-94 or Form I-94A bearing the same name as the passport and containing an endorsement of the alien's nonimmigrant status, as long as the 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 OR Documents that Establish Identity 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 AND Documents that Establish Employment Authorization 1. Social Security Account Number card other than one that specifies on the face that the issuance of the card does not authorize employment in the United States 2. Certification of Birth Abroad issued by the Department of State (Form FS-545) 3. Certification of Report of Birth issued by the Department of State (Form DS-1350) 4. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal 5. Native American tribal document 6. U.S. Citizen ID Card (Form I-197) 7. Identification Card for Use of Resident Citizen in the United States (Form I-179) 8. Employment authorization document issued by the Department of Homeland Security Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274) Form I-9 (Rev. 08/07/09) Y Page 5

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6 Form W-4 (2012) 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 2012 expires February 18, 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 $950 and includes more than $300 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 See Pub. 505, especially if your earnings exceed $130,000 (Single) or $180,000 (Married). Future developments. The IRS has created a page on IRS.gov for information about Form W-4, at Information about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted on that page. Personal Allowances Worksheet (Keep for your records.) A Enter 1 for yourself if no one else can claim you as a dependent A You are single and have only one job; or B Enter 1 if: { You are married, have only one job, and your spouse does not work; or... B Your wages from a second job or your spouse s wages (or the total of both) are $1,500 or less. 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.) C D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return D E Enter 1 if you will file as head of household on your tax return (see conditions under Head of household above).. E F 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 $61,000 ($90,000 if married), enter 2 for each eligible child; then less 1 if you have three to seven eligible children or less 2 if you have eight or more eligible children. If your total income will be between $61,000 and $84,000 ($90,000 and $119,000 if married), enter 1 for each eligible child... G H 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 { If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions For accuracy, and Adjustments Worksheet on page 2. complete all If you are single and have more than one job or are married and you and your spouse both work and the combined worksheets earnings from all jobs exceed $40,000 ($10,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to that apply. 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. Form W-4 Department of the Treasury Internal Revenue Service Separate here and give Form W-4 to your employer. Keep the top part for your records. 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. 1 Your first name and middle initial Last name OMB No Your social security number Home address (number and street or rural route) 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. City or town, state, and ZIP code 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 2012, 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 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 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 Q Form W-4 (2012)

7 Team Members must enter and exit the store through the customer entrances during regular store hours of operation. The back door shall be locked at all times and will be used only for deliveries and trash disposal. are not to be opened unless by management. Rules and Regulations Andy s is founded and operated on one basic premise that the key to success is complete customer SATISFACTION. We believe the way to accomplish this is to treat our Guests and Co-Workers with courtesy, respect and genuine concern for their well being. You have chosen to join us, and we hope it s at least partially because you share our philosophy. We ask that you combine your energy and talents with the operational expertise you will quickly learn, to help make our company everything it has the potential to become. The following contains general information concerning some of the rules and regulations of Andy s. These rules and regulations are not exhaustive or all-inclusive. UNIFORMS AND APPEARANCE Employees are to provide an Andy s T Shirt, visor, and apron and blue jeans in good repair. Blue jeans may not be torn or have holes in them. In order to provide a neat appearance, shirts tails are to be tucked in and pants must fit properly. Also, if pants have belt loops, a belt is required. T Shirts, visors, and aprons, will be purchased from Andy s Home Office ( Shirts will be priced according to size, Visors $7.00 and aprons $10.00) If for any reason you are no longer employed before you finish paying for uniforms the remaining amount will be held out of your last check. All employees are to report to work fit for duty, on time, and in complete uniform, including name tag and visor. Good personal hygiene is, of course, a requirement of your job. No partially uniformed Team Member will be allowed on the premises. No jackets, sweaters, or visual additions to a uniform will be allowed. During cold weather, Andy s jackets will be provided as required. Shoes must be of leather type material and dark in color. For your protection, no canvas or open toed shoes will be allowed, and the shoe must completely cover the foot. Shoe soles must be slip resistant. Make-up worn should be kept to a minimum. No exposed necklaces will be allowed and a maximum of one ring on each hand. Earrings should be no larger than a dime. They may not be the dangling type. No facial/tongue piercings allowed. Bracelets may not be worn (unless for medical reasons). For sanitary reasons, fingernails must be clean, trimmed, and free of fingernail polish and artificial nails. Hair must be neatly combed, restrained, and pulled off the front and top of shoulders if it is long. Hair restraints or hair additions, and color must present a neat and professional appearance. Also, hair must be worn or styled so that a visor or hat sits neatly and securely on the head. Andy s strives to present a clean-cut, neat image to our customers. Andy s continues to comply with State Health Department regulations, which require effective hair restraint by employees engaged in preparations, processing, and service of food products. Mustaches, beards, and sideburns must be neatly trimmed and well groomed. Any employee failing to conform to this policy may be subject to discipline, including discharge. No uniformed Team Member will be allowed in the dining area unless he is performing assigned duties. Off-duty Team Members are allowed in the dining area only when not in uniform and when visiting the store as a customer. Management has the final say on whether dress, uniform, and appearance are acceptable. GENERAL RULES AND REGULATIONS You have been hired as an employee at will, which means that you may leave Andy s for any reason or no reason at all. Andy s, in turn, reserves the right to terminate your employment at any time for any reason. Employees are required to attend all team meetings as scheduled by the Manager. Notes and important information are posted on the bulletin board(s) in the store. You are responsible for staying up to date and informed. Off duty Team Members will not be permitted in the back room except to check the work schedule or pick up their paychecks. This should never be done during peak business hours. A soft drink will be provided free of charge while on break or at manager s discretion. This is a privilege and will not be abused. After store closing, only the closing employees will be permitted to remain in the store. All doors and windows are to be locked, and Anyone operating any motorized food preparation equipment must be 18 years of age or older. The Manager on Duty must handle any and all customer complaints. Parking restrictions for employee s vehicles will be by direction of the store manager and must be followed without exception. A clean, neat, and orderly store is everybody s responsibility. If you see a piece of trash on the floor or parking lot, pick it up. Everything should be clean, in place, and ready to use. No Team Member should clock in for work prior to his scheduled shift unless directed by management. Team Members must have manager approval prior to clocking out even if at your scheduled time to leave. Any deviation from the work schedule will be by the direction of the Manager on Duty. Working off the clock is prohibited. In accordance with and in compliance with the Employee Polygraph Protection Act, employee polygraph examinations may be conducted in connection with certain ongoing investigations involving economic loss or injury to Andy s. Smoking will not be allowed while on duty. Payroll checks or personal checks may not be cashed by Team Members or members of the Management Team. The Manager on Duty should always answer the telephone. A Team Member may answer the phone only at the direction of the manager. The telephone should be answered with the greeting: Thank you for calling Andy s. May I help you? The store telephone is a business phone. Team Members may not use the telephone for incoming or outgoing personal calls. Team Members may use the phone with the Manager s permission in an emergency or to arrange transportation. No long distance calls or any calls that generate a fee are permitted unless business related. The use of cellular telephones is not allowed at work, unless on break. TEAM MEMBER BREAKS All Team Members will be given a 15 minute paid break if they are scheduled to work for more than four hours. If a Team Member who is scheduled to work for less than four hours, is asked to remain for more than four hours, he will be entitled to a 15 minute paid break. The Manager on Duty will give breaks. Breaks will be given at the discretion of the Manager when time and level of business permit. Breaks begin when a Team Member is sent on break and end 15 minutes later. If a Team Member who is on break is asked to return to his duties before the end of the 15 minute break, he will be allowed to finish the unused portion of his break when time and level of business permit. Employees may not leave the store during break. It is the responsibility of Andy s to make certain that all breaks are given as per this policy. It is your responsibility to bring to the attention of the Store Manager or Area Director any instance of a break you were eligible for and were not given. EMPLOYEE MEALS Employees will be furnished meals at half price of the total food purchase cost. Discounted items are excluded. A soft drink will be provided free of charge. Employee meals are for the individual employee only and will be provided only in the performance of a scheduled work shift. Employee meals must be eaten at the designated break area. Employees wishing to take their meal with them at the end of their scheduled work shift must leave the premises immediately. Employee meals cannot be saved or split. CODE OF CONDUCT Employees must always conduct themselves in a professional manner. Employees must present a well-groomed and well-mannered appearance when wearing the Andy s uniform. When visiting the store as a customer, you must not loiter or disrupt business. Try to leave personal problems behind when you come to work. If everyone comes to work with an enthusiastic and cooperative attitude, everyone s job will be easier.

8 No loitering on the premise will be permitted. Family and friends may not visit employees while at work. No firearms or weapons are allowed on the premises. It is Andy s policy to maintain a work place free from the effect of drug and alcohol abuse. The consumption, use, dispensing, possession, manufacture, transportation, sale, purchase, transfer, delivery, solicitation for, acceptance of, or distribution of alcohol and/or illegal drugs, narcotics, or controlled substances, and/or the misuse of prescription or over-the-counter drugs or medication (1) on or in Andy s property, (2) during working hours, or (3) while off duty in any manner that impairs work, renders an employee unfit for work, violates federal or state controlled substance laws or Andy s policies, or otherwise adversely affects Andy s reputation in the community will result in immediate discipline up to and including termination of employment. Drug and/or alcohol testing in accordance with applicable law may be required. Refusal to cooperate with a legal request for testing is grounds for immediate termination. In addition to disciplinary action, a positive screen may result in denial of benefits for on the job injuries as permitted by the law. Any employee who is convicted of, or pleads guilty or no contest to any criminal drug violation must report the conviction to the Manager or Director of Operations. Tampering with or falsifying the employee work schedule, timekeeping records or any Andy s records, the knowing submission of false information or the knowing omission of material information to Andy s may result in immediate termination. Employees must report to work fit for duty, on time and in complete uniform. Habitual unexcused absences or tardiness will not be tolerated. Andy s continues to comply with the provisions of the Family and Medical Leave Act, which provides eligible employees with up to 12 weeks of unpaid, job-protected leave in any 12 month period for specific family and medical reasons. A detailed explanation of Andy s FMLA policy may be found in Andy s Administration and Policy Manual, available at each store. Reasonable notice must be provided to management if you are unable to perform your scheduled work shift. If at all possible, you should find a suitable replacement for your shift and the Manager on Duty must approve this. No chewing gum will be allowed at any time. No talking will be permitted in the customer service area that is not related to business when customers are present. Your entire attention is to be placed on serving our valued customers, who provide us all with our jobs and salaries. No threats, profanity or horseplay will be tolerated. Any employee performing work duties in an unsafe manner, such as not following established safety rules and/or following proper use and cleaning of equipment may be subject to discipline, including discharge. Any theft by an employee or giving food products away will result in immediate dismissal. Arrest warrants will be issued and/or other legal action will be taken whenever the situation warrants prosecution. It is the policy of Andy s to promote and require a productive work environment and to comply with all applicable laws and regulations. Andy s will not tolerate any conduct by any employee which: improperly or illegally harasses, disrupts, or interferes with work performance or operations; creates or contributes to a work environment that is intimidating, offensive, or hostile to customers or co-workers; or discredits or adversely affects Andy s legitimate interests. While all forms of harassment and discrimination are prohibited, harassment based on sex, race, age, disability, religion, national origin, ethnicity, military status, pregnancy, or any other characteristic protected by applicable law, is specifically prohibited. Each supervisor and manager has a responsibility to help to maintain a workplace free of harassment. No supervisor is to suggest, threaten, or imply that refusal to submit to sexual advances will adversely affect an employee s employment or any condition of employment. Other harassing conduct, whether committed by supervisors, managers, non-management, or non-supervisor personnel, or persons who do not work for Andy s is also prohibited. Sexual harassment is defined as any unwelcome sexual advances, requests for sexual favors, and other verbal and physical conduct of a sexual nature including, but not limited to: sexual flirtation, touching, advances, or propositions; verbal or written abuse of a sexual nature; graphic or suggestive comments about an individual s dress or body, sexually degrading words to describe an individual; and the display in the workplace of sexually suggestive objects or pictures. Andy s management team members have been instructed that any fraternization with team members will not be tolerated. Complaints of harassment or discrimination should be directed to your supervisor or Area Director. Andy s will investigate the complaint and take appropriate action. If an employee is dissatisfied with the resolution of such a complaint, the employee may bring the complaint to the attention of the next higher level of management (Store Manager, Director of Operations, and Company President, in that order.) The customer is always right! Any arguing with or disrespect shown to our customers will result in the dismissal of the employee involved. Any action on or off premises or on or off duty, whether verbal or physical that adversely effects the safety, security, profitability, reputation, morale or any legitimate interests of Andy s is prohibited and may lead to discipline up to and including termination. Andy s will make reasonable accommodation to the known disabilities of applicants and employees. Failure to perform any legitimate assignment as directed by management or any other insubordination will not be tolerated. All employees will be paid in accordance with state and federal wage regulation. All raises and promotions will be based on performance, attitude, Andy s expert tests, ability, Company needs and budget and any other lawful considerations. Andy s strives to give performance evaluations semiannually. Andy s reserves the right to provide performance evaluations at its discretion at any time. Your rate of pay is a private matter to be discussed only with the person responsible for that rate. Terminated employees will not receive vacation or sick pay benefits upon termination. Vacation pay is an additional benefit provided for active, eligible employees. Employees, who are terminated, voluntarily or involuntarily, will receive their checks on the next regular scheduled payday. All uniforms must be returned complete, clean, and in good repair before final paycheck is released. Whenever possible, please notify your manager in advance if you will be leaving our employ. Give us an opportunity to find a replacement so that our customers will not suffer a reduction in service. Andy s may refuse to assign an employee to jobs involving food handling if the employee has an infectious or communicable disease that poses a risk that cannot be eliminated through reasonable accommodation. These rules and regulations are not all inclusive. Andy s reserves the right to counsel and/or discipline an employee on any matter not specifically addressed in these rules and regulations when such action would be in the best interest of the Company. Andy s reserves the right to amend these rules and regulations from time to time. Employees are expected to learn and comply with any changes that may be implemented. ACKNOWLEDGMENT I have read these rules and regulations and other information provided to me. I understand the contents of the rules and regulations and other information provided to me and I have discussed with my supervisor any portions of the rules and regulations and other information provided to me concerning which I desired clarification or explanation. I understand that it is my responsibility to know and to follow Andy s rules and regulations, whether or not contained in this document. I agree that my employment with Andy s is at will and can be terminated for any or no reason, at any time, by Andy s or by me. I understand that no representative of Andy s has any authority to enter into any agreement of employment for any specified period of time, terms, or conditions. I understand that these rules and regulations are not contractual and that Andy s reserves the right to revise, supplement, delete, modify, or vary from these rules and regulations in its sole discretion. Employee s Signature Manager s Signature Date Revised 5/1/2012