Welcome to Arizona PRN!

Transcription

1 Welcome to Arizona PRN! We are excited to have you join our team and fulfill your occupational needs. To speed up the hiring process, please provide us with the following: Physical with-in the past year TB or Chest X-Ray (x-rays over a year old require a TB questionnaire) MMR titers with positive results or proof of 2 vaccines (required for hospitals, hand written titers not accepted) Varicella titer with positive results or proof of 2 vaccines (required for hospitals) CPR (Healthcare Providers required for hospital staff) First Aid ACLS/PALS/NRP (specialty RN s only) CPI (behavioral health staff only) License/certificate Picture ID or Unexpired Passport Birth Certificate or Social Security Card (not needed if you have Passport) Fingerprint Card (required for Psych and LTC) Competency tests ( ed and completed online) Drug Screen (completed by AZPRN) Other(certain facilities may request more then what is listed above): Behavioral Health Technicians please also bring the following: High School Diploma or GED College Diploma/Transcripts Continuing education certificates or transcripts

2 6103 E. Grant Rd. Tucson, AZ Phone Fax *Applicant please fill out top box only has applied for a position as with Arizona PRN, LLC and provided your name as a professional reference. Any information included in this reference will be held in the strictest of confidence. Your anticipated cooperation is appreciated. My signature below authorizes the release of the requested information to Arizona PRN, LLC: Applicant Signature Social Security #(last 4 digits) Position Held Performance Evaluation Clinical Skills Job Performance Understanding of Position Works well in a Team Reliability Attendance/Punctuality Appearance Above Average Average Below Average N/A Comments Position Held s of Employment If not eligible for rehire, please explain: Facility Name: Reference Name: Signature Office Use Only: Verbal Reference Written Reference :

3 6103 E. Grant Rd. Tucson, AZ Phone Fax *Applicant please fill out top box only has applied for a position as with Arizona PRN, LLC and provided your name as a professional reference. Any information included in this reference will be held in the strictest of confidence. Your anticipated cooperation is appreciated. My signature below authorizes the release of the requested information to Arizona PRN, LLC: Applicant Signature Social Security #(last 4 digits) Position Held Performance Evaluation Clinical Skills Job Performance Understanding of Position Works well in a Team Reliability Attendance/Punctuality Appearance Above Average Average Below Average N/A Comments Position Held s of Employment If not eligible for rehire, please explain: Facility Name: Reference Name: Signature Office Use Only: Verbal Reference Written Reference :

4 6103 E. Grant Rd. Tucson, AZ Phone Fax *Applicant please fill out top box only has applied for a position as with Arizona PRN, LLC and provided your name as a professional reference. Any information included in this reference will be held in the strictest of confidence. Your anticipated cooperation is appreciated. My signature below authorizes the release of the requested information to Arizona PRN, LLC: Applicant Signature Social Security #(last 4 digits) Position Held Performance Evaluation Clinical Skills Job Performance Understanding of Position Works well in a Team Reliability Attendance/Punctuality Appearance Above Average Average Below Average N/A Comments Position Held s of Employment If not eligible for rehire, please explain: Facility Name: Reference Name: Signature Office Use Only: Verbal Reference Written Reference :

5 CNA/BHT/OR Tech Work Experience Checklist Employee Name: : 1 = No Knowledge/No Experience 2 = Understand Theory/Minimal Experience 3 = Knowledge/Competent in Skill 4 = Strong Knowledge/Proficient In Skill Certified Nursing Assistant Competency Level Experience in This Type of Facility Type s of Experience I&O Vitals CPR 1:1 Only Acute Care Private Duty Hospice Nursery Blood Glucose Monitor Type: Sitter Competency Level Type s of Experience Acute Care Private Duty Hospice Nursery Behavioral Health Technician Competency Level Experience in this Type of Facility Type s of Experience Crisis Intervention CPR 1:1 Groups Adolescents Adults OR Tech Competency Level Type s of Experience General Central Supply ENT L&D Laparoscopic Laser Neurosurgery OB/GYN Open Heart Opthalmic OR Orthopedic Plastic Thoracic Total Joint Urology Vascular Other: Employee Signature Supervisor Signature

6 CNA Skills Competency Checklist Employee Name: : 1 = No Knowledge/No Experience 2 = Understand Theory/Minimal Experience 3 = Knowledge/Competent in Skill 4 = Strong Knowledge/Proficient In Skill SKILLS SKILLS Partial/Complete Bed Bath Oral Care/Peri-Care Sitz Bath LINEN CHANGE: Occupied Unoccupied Shave Prep/Acrub Double Bag Isolation Technique Monitor/Chart Nutritional Intake BASIC CNA TASKS: Daily weight: Standing Daily weight: Bed Set-up/pass meal trays Feeding Patients Monitor/charting bowel & urinary patterns Enemas Harris Flush Rectal Tubes D/C Foley Catheters EMPTYING & RECORDING OUTPUT FROM: NG Tubes Hemovacs Jackson Pratt T-Tubes Foley Catheters Foley Care SPECIMENT COLLECTIONS: Urine Stool Sputum Stool Occult Blood Ambulate, reposition, & turn patients Instruction on coughing and deep breathing Instruction on incentive spirometer Instruct & assist pts with leg exercises TED hose/ace bandage application Decubitus care and charting Application and maintenance of: Ice Packs Application and maintenance of: K Packs Setting up post-op/new admission rooms Post-mortem Care Obtaining and charting vitals Assist with patients transfers Stocking Unit supplies Completing diet menus stuffing patient charts Monitoring/maintaining unit stock items POPULATIONS SERVED: Children Adolescent Adult Geriatric Employee Signature Supervisor Signature

7 Joint Commission Yearly In-services Tuberculosis Back From the Past Service Excellence Protecting Your Back Bloodborne Pathogens Infection Control Ending Sexual Harassment Healthcare Violence Age-Specific Care Hazardous Communication Diversity Safety Orientation Fire Safety HIPAA Employee Signature Supervisor Signature

8 Acknowledgement of Confidential Patient Health Information I, (print name) acknowledge the confidentiality of patient health care information (confidential patient information) that I may receive or have access to during the course of providing patient care services at facilities to which I am assigned. I shall maintain the confidentiality of confidential patient information, and in doing so, shall comply with all applicable state and federal laws and regulations, including without limitation, the privacy provisions under the Health Insurance Portability Accountability Act of 1996 (HIPAA) and the policies and procedures of each participating facilities to which I am assigned. My agreement to maintain the confidentiality of confidential patient information shall survive the termination of my employment with Arizona PRN, and the conclusion of any assignments at a participating hospital under the Nurse Registry Program. Employee Signature

9 Physician Statement Statement of Satisfactory Health is found to be in good health without evidence of communicable disease and is free to work without restrictions at this time. Healthcare Provider Name: Address: Phone: Provider Signature

10 Hepatitis-B Vaccination Consent/Declination Form Arizona PRN has provided me with information on the following: 1. OSHA guidelines regarding bloodborne pathogen regulations. 2. Where I can receive the vaccination. 3. I have received and reviewed the bloodborne pathogens exposure control plan including: All about hazardous material All about infection control All about universal precautions Hepatitis B In addition, the following is a true statement regarding the status of series of three Hepatitis B vaccinations: I understand that due to my occupational exposure to blood/infectious materials, I may be at risk of acquiring the Hepatitis B infection. I have been given the opportunity to be vaccinated with the Hepatitis B vaccine; however I decline at this time. If in the future I choose to receive the vaccine, Arizona PRN will refer me to a proper source. I have received the series of three vaccinations at the following location(s) on the following dates: 1. : 2. : 3. : I have been instructed on where I can receive the Hepatitis B vaccination series and if I choose to receive the vaccinations, I will report this to Arizona PRN upon completion. Employee Signature

11 Varicella (Chickenpox) Screening Questionnaire 1. Have you ever had the chickenpox? Yes No Unknown 2. If you answered NO or UNKNOWN in question number 1, have you had a Varicella vaccine or titer? Yes No 3. If you answered YES to question number 2, please provide records of vaccination or titer results. Employee Name Employee Signature

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13 FCRA DISCLOSURE AND ACKNOWLEDGMENT IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING AUTHORIZATION DISCLOSURE REGARDING BACKGROUND INVESTIGATION Arizona PRN, LLC ( the Company ) may obtain information about you for employment purposes from a third party consumer reporting agency. Thus, you may be the subject of a consumer report and/or an investigative consumer report which may include information about your criminal history, social security verification, motor vehicle records ( driving records ), verification of your education or employment history, or other background checks. An investigative consumer report may include information about your character, general reputation, personal characteristics, and/or mode of living, and which can involve personal interviews with sources such as your neighbors, friends, or associates. Please be advised that the nature and scope of the most common form of investigative consumer report obtained is an investigation into your education and/or employment history. You have the right, upon written request made within a reasonable time, to request whether a consumer report has been run about you, and disclosure of the nature and scope of any investigative consumer report, and to request a copy of your report. The report may be generated by Universal Background Screening (7720 North 16th Street, Suite 200, Phoenix, AZ 85020, or another outside organization. The scope of this notice and authorization is all-encompassing, however, allowing the Company to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and, if you are hired, throughout your employment to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report. New York and Maine applicants or employees only: You have the right to inspect and receive a copy of any investigative consumer report requested by the Company by contacting the consumer reporting agency identified above directly. You may also contact the Company to request the name, address and telephone number of the nearest unit of the consumer reporting agency designated to handle inquiries, which the Company shall provide within 5 days. New York applicants or employees only: Upon request, you will be informed whether or not a consumer report was requested by the Company, and if such report was requested, informed of the name and address of the consumer reporting agency that furnished the report. By signing below, you also acknowledge receipt of Article 23-A of the New York Correction Law. Oregon applicants or employees only: Information describing your rights under federal and Oregon law regarding consumer identity theft protection, the storage and disposal of your credit information, and remedies available should you suspect or find that the Company has not maintained secured records is available to you upon request. Washington State applicants or employees only: You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act. ACKNOWLEDGMENT AND AUTHORIZATION I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION (above) and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT (separate document) and certify that I have read and understand both of those documents. I hereby authorize the obtaining of consumer reports and/or investigative consumer reports by the Company at any time after receipt of this authorization and, if I am hired, throughout my employment, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Universal Background Screening, another outside organization acting on behalf of the Company, and/or the Company itself. I agree that a facsimile ( fax ), electronic or photographic copy of this Authorization shall be as valid as the original. New York applicants or employees only: By signing below, you also acknowledge receipt of Article 23-A of the New York Correction Law. Minnesota and Oklahoma applicants or employees only: Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Company. California applicants or employees only: By signing below, you also acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW. Please check this box if you would like to receive a copy of an investigative consumer report or consumer credit report at no charge if one is obtained by the Company whenever you have a right to receive such a copy under California law. Signature Full Name (First/Middle/Last) Social Security Number (SSN)* Driver License State / Number of Birth* *This information will be used for background screening purposes only and will not be used as hiring criteria.

14 Work Related Injuries Acknowledgment! I understand that it is my responsibility to obey all safety rules and use caution when on an assignment! Under Arizona PRN workers compensation policy, I am responsible for reporting any and all work related injuries to my supervisor and the director of HR within 24 hours of the incident.! I will immediately fill out the First Report of Injury form, located at the office on 6103 E. Grant Road, Tucson, AZ 85712, even if no medical attention is needed.! If medical attention is required, I understand that in order for it to be covered under my workers compensation plan, I must seek treatment within 48 hours of the injury. I will also be required to complete a drug screen. Employee Signature Arizona PRN Witness

15 Arizona Form A-4 Employee s Arizona Withholding Election 2016 Type or print your Full Name Your Social Security Number Home Address number and street or rural route City or Town State ZIP Code Choose either box 1 or box 2: 1 Withhold from gross taxable wages at the percentage checked (check only one percentage): 0.8% 1.3% 1.8% 2.7% 3.6% 4.2% 5.1% Check this box and enter an extra amount to be withheld from each paycheck... $ 2 I elect an Arizona withholding percentage of zero, and I certify that I expect to have no Arizona tax liability for the current taxable year. I certify that I have made the election marked above. SIGNATURE DATE Employee s Instructions Arizona law requires your employer to withhold Arizona income tax from your wages for work done in Arizona. This amount is applied to your Arizona income tax due when you file your tax return. The amount withheld is a percentage of your gross taxable wages of every paycheck. You may also have your employer withhold an extra amount from each paycheck. Complete this form to select a percentage and any extra amount to be withheld from each paycheck. What are my Gross Taxable Wages? For withholding purposes, your gross taxable wages are the wages that will generally be in box 1 of your federal Form W-2. It is your gross wages less any pretax deductions, such as your share of health insurance premiums. New Employees Complete this form in the first five days of employment to select an Arizona withholding percentage. You may also have your employer withhold an extra amount from each paycheck. If you do not file this form, the department requires your employer to withhold 2.7% of your gross taxable wages. Current Employees If you want to change the current amount withheld, you must file this form to change the Arizona withholding percentage or change the extra amount withheld. What Should I do With Form A-4? Give your completed Form A-4 to your employer. ADOR (15) Electing a Withholding Percentage of Zero You may elect an Arizona withholding percentage of zero if you expect to have no Arizona income tax liability for the current year. Arizona tax liability is gross tax liability less any tax credits, such as the family tax credit, school tax credits, or credits for taxes paid to other states. If you make this election, your employer will not withhold Arizona income tax from your wages for payroll periods beginning after the date you file the form. Zero withholding does not relieve you from paying Arizona income taxes that might be due at the time you file your Arizona income tax return. If you have an Arizona tax liability when you file your return or if at any time during the current year conditions change so that you expect to have a tax liability, you should promptly file a new Form A-4 and choose a percentage that applies to you. Voluntary Withholding Election by Certain Nonresident Employees Compensation earned by nonresidents while physically working in Arizona for temporary periods is subject to Arizona income tax. However, under Arizona law, compensation paid to certain nonresident employees is not subject to Arizona income tax withholding. These nonresident employees need to review their situations and determine whether they should elect to have Arizona income taxes withheld from their Arizona source compensation. Nonresident employees may request that their employer withhold Arizona income taxes by completing this form to elect Arizona income tax withholding.

16 Form W-4 (2016) 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 2016 expires February 15, 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 $1,050 and includes more than $350 of unearned income (for example, interest and dividends). Exceptions. An employee may be able to claim exemption from withholding even if the employee is a dependent, if the employee: Is age 65 or older, Is blind, or Will claim adjustments to income; tax credits; or itemized deductions, on his or her tax return. The exceptions do not apply to supplemental wages greater than $1,000,000. 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. Information about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted at 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 $2,000 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 $70,000 ($100,000 if married), enter 2 for each eligible child; then less 1 if you have two to four eligible children or less 2 if you have five or more eligible children. If your total income will be between $70,000 and $84,000 ($100,000 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 $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 that apply. 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. Employee's Withholding Allowance Certificate Form W-4 Department of the Treasury Whether you are entitled to claim a certain number of allowances or exemption from withholding is Internal Revenue Service 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) City or town, state, and ZIP code 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 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 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.) 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 (2016)

17 Form W-4 (2016) 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 2016 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes, medical expenses in excess of 10% (7.5% if either you or your spouse was born before January 2, 1952) of your income, and miscellaneous deductions. For 2016, you may have to reduce your itemized deductions if your income is over $311,300 and you are married filing jointly or are a qualifying widow(er); $285,350 if you are head of household; $259,400 if you are single and not head of household or a qualifying widow(er); or $155,650 if you are married filing separately. See Pub. 505 for details... 1 $ $12,600 if married filing jointly or qualifying widow(er) 2 Enter: { $9,300 if head of household } $ $6,300 if single or married filing separately 3 Subtract line 2 from line 1. If zero or less, enter $ 4 Enter an estimate of your 2016 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 2016 Form W-4 worksheet in Pub. 505.) $ 6 Enter an estimate of your 2016 nonwage income (such as dividends or interest) $ 7 Subtract line 6 from line 5. If zero or less, enter $ 8 Divide the amount on line 7 by $4,050 and enter the result here. Drop any fraction Enter the number from the Personal Allowances Worksheet, line H, page 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) 1 2 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 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 Note: 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 Enter the number from line 1 of this worksheet Subtract line 5 from line Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here $ 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 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 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 1 Table 2 Married Filing Jointly All Others Married Filing Jointly All Others If wages from LOWEST paying job are Enter on line 2 above $0 - $6, ,001-14, ,001-25, ,001-27, ,001-35, ,001-44, ,001-55, ,001-65, ,001-75, ,001-80, , , , , , , , , , , ,001 and over 15 If wages from LOWEST paying job are Enter on line 2 above $0 - $9, ,001-17, ,001-26, ,001-34, ,001-44, ,001-75, ,001-85, , , , , , , ,001 and over 10 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. If wages from HIGHEST paying job are Enter on line 7 above $0 - $75,000 $610 75, ,000 1, , ,000 1, , ,000 1, , ,000 1, ,001 and over 1,600 If wages from HIGHEST paying job are Enter on line 7 above $0 - $38,000 $610 38,001-85,000 1,010 85, ,000 1, , ,000 1, ,001 and over 1,600 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 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.

18 Employee Direct Deposit Enrollment Form Payroll Manager Please complete this section and enter data into your ADP Payroll system for employee enrollment. Then contact your CSR or AE for further instructions on how to update your employee s direct deposit information to ADP. NOTE: YOUR COMPANY NAME MUST BE FILLED IN BEFORE DISTRIBUTING THIS FORM TO YOUR EMPLOYEE FOR COMPLETION. (Please print.) Company Code: Company Name: Employee File Number: (referred to herein as Employer ) Payroll Mgr. Name: Payroll Mgr. Signature: To enroll in Full Service Direct Deposit, simply fill out this form and give it to your payroll manager. Attach a voided check for each checking account not a deposit slip. If depositing to a savings account, ask your bank to give you the Routing/Transit Number for your account. It isn t always the same as the number on a savings deposit slip. This will help ensure that you are paid correctly. Below is a sample check MICR line, detailing where the information necessary to complete this form can be found. Memo Routing/Transit # (A 9-digit number always between these two marks) Checking Account # Check # (this number matches the number in the upper right corner of the check not needed for sign-up) Important! Please read and sign before completing and submitting. I hereby authorize Employer, either directly or through its payroll service provider, to deposit any amounts owed me, by initiating credit entries to my account at the financial institution (hereinafter Bank ) indicated on this form. Further, I authorize Bank to accept and to credit any credit entries indicated by Employer, either directly or through its payroll service provider, to my account. In the event that Employer deposits funds erroneously into my account, I authorize Employer, either directly or through its payroll service provider, to debit my account for an amount not to exceed the original amount of the erroneous credit. This authorization is to remain in full force and effect until Employer and Bank have received written notice from me of its termination in such time and in such manner as to afford Employer and Bank reasonable opportunity to act on it. Employee Name: Employee Signature: Social Security #: - - : Account Information The last item must be for the remaining amount owed to you. To distribute to more accounts, please complete another form. Make sure to indicate what kind of account, along with amount to be deposited, if less than your total net paycheck. 1. Bank Name/City/State: Routing/Transit #: Account Number: Checking Savings Other I wish to deposit: $. or Entire Net Amount 2. Bank Name/City/State: Routing/Transit #: Account Number: Checking Savings Other I wish to deposit: $. or Entire Net Amount 3. Bank Name/City/State: Routing/Transit #: Account Number: Checking Savings Other I wish to deposit: $. or Entire Net Amount ATTENTION PAYROLL MANAGER: Employers must keep each original employee enrollment form on file as long as the employee is using FSDD, and for two years thereafter. The ADP Logo is a registered trademark of ADP of North America, Inc Printed in USA 2004, 2002, 2001, 2000, 1999, 1998 ADP, Inc.

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