An A.M. Herbst Company

248-545-5121 734-458-9708

Troy Livonia Troymm@merrymaids.net Livonia@merrymaids.net

New Hire Checklist

� Employee Agreement

� Uniform Rental Agreement

� Form I-9

� Federal W-4

� State W-4

� State New Hire Report

� New Employee Information Sheet

� Direct Deposit Paperwork

� Financial Training Document

� Employee Drug Screen

1

Merry Maids # 372/373/946/947 A. M. Herbst Company, Inc

EMPLOYMENT AGREEMENT This Employment Agreement (this agreement) is made effective as of ________________ by and between Merry

Maids, (the Employer), of 215 E Big Beaver Road, Suite 150, Troy, MI 48083 and

___________________________________________________, (the employee) whose address is as stated on the

attached application.

A. Employer is engaged in the business of residential and light office cleaning services.

B. Employer desires to have the services of the Employee.

C. Employee is willing to be employed by Employer.

D. Employment is offered on an "at will" basis.

Therefore, the parties agree as follows:

1.0 EMPLOYMENT. Employer shall employ Employee as a Team Member to provide cleaning services as described

in the Merry Maids Training Manual. Employee accepts and agrees to such employment, subject to the general

supervision, advice and direction of Employer and the Employer's Supervisory Personnel. Employee shall also perform

(i) such other duties as are customarily performed by an employee in a similar position, and (ii) such other and

unrelated services and duties as may be assigned to Employee from time to time by Employer.

2.0 BEST EFFORTS OF EMPLOYEE. Employee agrees to perform faithfully, industriously, and to the best of

Employee's ability, experience, and talents, all of the duties that may be required by the express and implicit terms of

this agreement, to the reasonable satisfaction of Employer. Such duties shall be provided at such place(s) as the needs,

business, or opportunities of the Employer may require from time to time.

3.0 WAGE PAYMENTS. Employer shall make wage payments to the Employee based upon a percentage basis

which is determined by the Cleaning Fee, Service Fee, and resultant Payroll Fee, and the Team Structure as described

in the Company Policy Manual. The wage payments will be made weekly, no later than seven days after the payroll

period that ended on the preceding Saturday.

a. Accounting. The Employer shall maintain records in sufficient detail for purposes of determining the wage

payment. The Employer shall provide to Employee a written accounting that sets forth the manner in which the wage

payment was calculated.

b. Right to Inspect. The Employee shall have the right to inspect the Employer's records for the limited

purpose of verifying the calculation of the wage payments, subject to such restrictions as Employer may reasonably

impose to protect the confidentiality of the records. Such inspections shall be made during reasonable business hours as

may be set by Employer.

4.0 REIMBURSEMENT FOR EXPENSES. The Employer shall reimburse Employee for the "out - of - pocket"

expenses for driving. The rate per mile is established in the Company Policy Manual and may be changed from time to

time. The mileage distance is determined by the most expedient direct path from one jobsite to the next.

5.0 RECOMMENDATIONS FOR IMPROVING OPERATIONS. Employee shall be encouraged to provide

Employer with all information, suggestions, and recommendations regarding Employer's business, of which Employee

has knowledge that will be of benefit to Employer.

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6.0 CONFIDENTIALITY. Employee recognizes that Employer has and will have information regarding the

following:

* Customer Lists,

* Trade Secrets,

* Products and Processes,

* Business Affairs,

* Future Plans,

* Prices, Costs, and Discounts,

and other vital information which are valuable, special and unique assets of Employer. Employee agrees to not at any

time or in any manner, either directly or indirectly, divulge, disclose, or communicate in any manner any information to

a third party without the prior written consent of the Employer. Employee will protect the information and treat it as

strictly confidential. A violation by Employee of this paragraph shall be a material violation of this agreement and will

justify legal and/or equitable relief.

7.0 UNAUTHORIZED DISCLOSURE OF INFORMATION. If it appears that Employee has disclosed, or has

threatened to disclose, information in violation of this agreement, Employer shall be entitled to an injunction to restrain

Employee from disclosing, in whole or in part, such information, or from providing any services to any party to whom

such information has been disclosed or may be disclosed. Employer shall not be prohibited by this provision from

pursuing other remedies, including a claim for losses and damages.

8.0 CONFIDENTIALITY AFTER TERMINATION OF EMPLOYMENT. The confidentiality provisions of this

agreement shall remain in full force and effect for a one-year period after the termination of Employee's employment.

9.0 NON-COMPETE AGREEMENT. Recognizing that the various items of information are special and unique

assets of the company, Employee agrees and covenants that for a period of one year following termination of this

agreement, whether such termination was voluntary or involuntary, Employee will not directly or indirectly engage in

any business competitive with Employer. This covenant shall apply to the geographical area within a seventy-five mile

radius of the company location. Directly or indirectly engaging in any competitive business includes, but is not limited

to, (i) engaging in a business as owner, partner, or agent, (ii) becoming an employee of any third party that is engaged

in such business, (iii) becoming interested in any such business, or (iv) soliciting any customer of Employer for the

benefit of a third party that is engaged in such business. Employee agrees that this non-compete provision will not

adversely affect the Employee's livelihood.

10.0 EMPLOYEE'S INABILITY TO CONTRACT FOR EMPLOYER. Employee shall not have the right to make

any contracts or commitments for or on behalf of Employer without first obtaining the express written consent of

Employer.

11.0 TERM/TERMINATION. Employee's employment under this agreement shall be for an unspecified term on an

"at will" basis. This agreement may be terminated by either party upon seven days written notice. If Employee is in

violation of this agreement, Employer may terminate employment without notice and without compensation to

Employee only to the date of such termination. The compensation paid under this agreement shall be the Employer's

exclusive remedy.

12.0 COMPLIANCE WITH EMPLOYER'S RULES. Employee agrees to comply with all established rules,

regulations, policies, and procedures of Employer.

13.0 RETURN OF PROPERTY. Upon termination of this agreement, Employee shall deliver all property, including

keys, records, notes, data, memoranda, books, communication devices, and equipment, that is in the Employee's

possession or under the Employee's control which is Employer's property or related to Employer's business.

14.0 NOTICES. All notices required or permitted under this agreement shall be in writing and shall be deemed

delivered when delivered in person or deposited in the US Mail, postage paid, addressed to the Employer and

Employee as stated in paragraph 1.0 of this agreement. Such addresses may be changed by either party by providing

written notice in the manner set forth.

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15.0 ENTIRE AGREEMENT. This agreement contains the entire agreement of the parties and there are no other

promises or conditions in any other agreement whether oral or written. This agreement supersedes any prior written or

oral agreements between the parties.

16.0 AMENDMENT. This agreement may be modified if the amendment is made in writing and signed by both

parties.

17.0 SEVERABILITY. If any provision of this agreement shall be held to be invalid or unenforceable for any reason,

the remaining provisions shall continue to be valid and enforceable.

18.0 WAIVER OF CONTRACTUAL RIGHT. The failure of either party to enforce any provision of this agreement

shall not be construed as a waiver or limitation of that party's right to subsequently enforce and compel strict

compliance with every provision of this agreement.

19.0 APPLICABLE LAW. The laws of the State of Michigan shall govern this agreement.

EMPLOYER: EMPLOYEE:

Merry Maids

By: _______________________________ By: _________________________

Title: ______________________________

An A.M. Herbst Company

Uniform Agreement

I, ___________________________, agree to enroll to be in proper uniform each day I attend work. This includes khaki pants1, uniform shirt, and slip resistant footwear. Uniform Options Pants (please initial next to your preferred option) ____ I agree to enroll in the Uniform Rental Program whereas I am provided 11 pairs of pants. This enrollment agreement is automatically cancelled upon the termination of my employment. Upon cancellation, I accept the responsibility to see that all garments assigned to me are returned. In the event all garments are not returned, I authorize A.M. Herbst, Inc. to deduct from my salary the cost of the missing garments. The replacement rates agreed to between A.M. Herbst, Inc. and Cintas Corporation are as follows: Item: Uniform Pant Replacement Value: $7.22 each Units Issued: 11 ____ I decline enrollment in the Uniform Rental Program and will provide my own khaki pants. I agree to replace and/or repair any garments deemed unsatisfactory by the Management Staff. Shirts ____ I will be provided 5 Merry Maids uniform shirts. I have the option of purchasing additional shirts from the office via payroll deduction for $15/ea. ____ I agree to repair and/or replace, at my own expense, any garments deemed unsatisfactory by the Management Staff. Shoes ____ I understand it is my responsibility to provide slip resistant shoes to be worn while performing my job responsibilities.

Employee Date Manager Date

1 Khaki shorts or Khaki capri pants may be substituted for khaki pants during periods of warmer weather. This option will be at employee expense.

Troy Office Livonia Office 215 E. Big Beaver Rd. 14800 Farmington Rd. Suite 150 Suite 105 Troy, MI 48083 Livonia, MI 48154 troymm@merrymaids.net livonia@merrymaids.net

Form W-4 (2010)Purpose. Complete Form W-4 so that youremployer can withhold the correct federal incometax from your pay. Consider completing a newForm W-4 each year and when your personal orfinancial situation changes.

Head of household. Generally, you may claimhead of household filing status on your taxreturn only if you are unmarried and pay morethan 50% of the costs of keeping up a homefor yourself and your dependent(s) or otherqualifying individuals. See Pub. 501,Exemptions, Standard Deduction, and FilingInformation, for information.

Exemption from withholding. If you areexempt, complete only lines 1, 2, 3, 4, and 7and sign the form to validate it. Your exemptionfor 2010 expires February 16, 2011. SeePub. 505, Tax Withholding and Estimated Tax.

Check your withholding. After your Form W-4takes effect, use Pub. 919 to see how theamount you are having withheld compares toyour projected total tax for 2010. See Pub.919, especially if your earnings exceed$130,000 (Single) or $180,000 (Married).

Basic instructions. If you are not exempt,complete the Personal Allowances Worksheetbelow. The worksheets on page 2 further adjustyour withholding allowances based on itemizeddeductions, certain credits, adjustments toincome, or two-earners/multiple jobs situations.

Two earners or multiple jobs. If you have aworking spouse or more than one job, figurethe total number of allowances you are entitledto claim on all jobs using worksheets from onlyone Form W-4. Your withholding usually willbe most accurate when all allowances areclaimed on the Form W-4 for the highestpaying job and zero allowances are claimed onthe others. See Pub. 919 for details.

Personal Allowances Worksheet (Keep for your records.)

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

● You are single and have only one job; orEnter “1” if:B ● 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.� �

Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse ormore than one job. (Entering “-0-” may help you avoid having too little tax withheld.)

CC

Enter number of dependents (other than your spouse or yourself) you will claim on your tax returnD D

E E

F F

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 H● If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions

and Adjustments Worksheet on page 2.For accuracy,complete allworksheetsthat apply.

● If you have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed$18,000 ($32,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld.

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

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

OMB No. 1545-0074Employee’s Withholding Allowance CertificateW-4Form

Department of the TreasuryInternal Revenue Service

� Whether you are entitled to claim a certain number of allowances or exemption from withholding issubject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

Type or print your first name and middle initial.1 Last name 2 Your social security number

Home address (number and street or rural route) MarriedSingle3 Married, but withhold at higher Single rate.

City or town, state, and ZIP code

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

55 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2)$66 Additional amount, if any, you want withheld from each paycheck

7 I claim exemption from withholding for 2010, 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.

7If you meet both conditions, write “Exempt” here �

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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(Form is not valid unless you sign it.) � Date �

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

Enter “1” if you have at least $1,800 of child or dependent care expenses for which you plan to claim a credit

4 If your last name differs from that shown on your social security card,check here. You must call 1-800-772-1213 for a replacement card. �

Cat. No. 10220Q

Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above)

Note. You cannot claim exemption fromwithholding if (a) your income exceeds $950and includes more than $300 of unearnedincome (for example, interest and dividends)and (b) another person can claim you as adependent on his or her tax return.

Nonwage income. If you have a large amountof nonwage income, such as interest ordividends, consider making estimated tax

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

G● 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 plus “1” additional if you have six or more eligible children.

● 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 or more eligible children.

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

Tax credits. You can take projected taxcredits into account in figuring your allowablenumber of withholding allowances. Credits forchild or dependent care expenses and thechild tax credit may be claimed using thePersonal Allowances Worksheet below. SeePub. 919, How Do I Adjust My TaxWithholding, for information on convertingyour other credits into withholding allowances.

Nonresident alien. If you are a nonresidentalien, see Notice 1392, Supplemental FormW-4 Instructions for Nonresident Aliens, beforecompleting this form.

For Privacy Act and Paperwork Reduction Act Notice, see page 2. Form W-4 (2010)

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

payments using Form 1040-ES, Estimated Taxfor Individuals. Otherwise, you may oweadditional tax. If you have pension or annuityincome, see Pub. 919 to find out if you shouldadjust your withholding on Form W-4 or W-4P.

2010

Page 2Form W-4 (2010)

Deductions and Adjustments WorksheetNote. Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.

Enter an estimate of your 2010 itemized deductions. These include qualifying home mortgage interest,charitable contributions, state and local taxes, medical expenses in excess of 7.5% of your income, andmiscellaneous deductions

1

$1$11,400 if married filing jointly or qualifying widow(er)

$$8,400 if head of household 2Enter:2$5,700 if single or married filing separately ��

$3 Subtract line 2 from line 1. If zero or less, enter “-0-” 3$Enter an estimate of your 2010 adjustments to income and any additional standard deduction. (Pub. 919)4$5Add lines 3 and 4 and enter the total. (Include any amount for credits from Worksheet 6 in Pub. 919.)5$6Enter an estimate of your 2010 nonwage income (such as dividends or interest)6$7Subtract line 6 from line 5. If zero or less, enter “-0-”7

Divide the amount on line 7 by $3,650 and enter the result here. Drop any fraction8 8Enter the number from the Personal Allowances Worksheet, line H, page 19 9Add 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

1010

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.1Enter 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, ifyou are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter morethan “3.” 2

3 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 3

Note. If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4–9 below to figure the additionalwithholding amount necessary to avoid a year-end tax bill.

Enter the number from line 2 of this worksheet4 4Enter the number from line 1 of this worksheet5 5Subtract line 5 from line 46 6

$Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here7 7$Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed8 8

Divide line 8 by the number of pay periods remaining in 2010. For example, divide by 26 if you are paidevery two weeks and you complete this form in December 2009. 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

$9

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on thisform to carry out the Internal Revenue laws of the United States. Internal Revenue Codesections 3402(f)(2) and 6109 and their regulations require you to provide thisinformation; 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 singleperson who claims no withholding allowances; providing fraudulent information maysubject you to penalties. Routine uses of this information include giving it to theDepartment of Justice for civil and criminal litigation, to cities, states, the District ofColumbia, and U.S. commonwealths and possessions for use in administering their taxlaws, and using it in the National Directory of New Hires. We may also disclose thisinformation to other countries under a tax treaty, to federal and state agencies toenforce federal nontax criminal laws, or to federal law enforcement and intelligenceagencies to combat terrorism.

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

4

Table 1All OthersMarried Filing Jointly

If wages from LOWESTpaying job are—

Table 2All OthersMarried Filing Jointly

If wages from HIGHESTpaying job are—

Enter online 7 above

If wages from HIGHESTpaying job are—

Enter online 7 above

Enter online 2 above

If wages from LOWESTpaying job are—

You are not required to provide the information requested on a form that issubject to the Paperwork Reduction Act unless the form displays a valid OMBcontrol number. Books or records relating to a form or its instructions must beretained as long as their contents may become material in the administration ofany Internal Revenue law. Generally, tax returns and return information areconfidential, as required by Code section 6103.

Enter online 2 above

0123456789

10

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

$0 -7,001 -

10,001 -16,001 -22,001 -27,001 -35,001 -44,001 -50,001 -55,001 -65,001 -72,001 -85,001 -

105,001 -115,001 -

$7,000 -10,000 -16,000 -22,000 -27,000 -35,000 -44,000 -50,000 -55,000 -65,000 -72,000 -85,000 -

130,001 - and over

0123456789

101112131415

$0 -6,001 -

12,001 -19,001 -26,001 -35,001 -50,001 -65,001 -80,001 -90,001 -

$6,000 -12,000 -19,000 -26,000 -35,000 -50,000 -65,000 -80,000 -90,000 -

120,000 -120,001 and over

$0 -65,001 -

120,001 -185,001 -

$550910

1,0201,2001,280330,001 and over

$65,000120,000185,000330,000

$0 -35,001 -90,001 -

165,001 -

$550910

1,0201,2001,280370,001 and over

$35,00090,000

165,000370,000

105,000 -115,000 -130,000 -

5. Are you a new employee?

9. Employee's Signature

Home Address (No., Street, P.O. Box or Rural Route)

3. Type or Print Your First Name, Middle Initial and Last Name

EMPLOYEE'S MICHIGAN WITHHOLDING EXEMPTION CERTIFICATESTATE OF MICHIGAN - DEPARTMENT OF TREASURYMI-W4

(Rev. 8-08)

This certificate is for Michigan income tax withholding purposes only. You must file a revised form within 10 days if your exemptions decrease or your residency status changes from nonresident to resident. Read instructions below before completing this form.

Issued under P.A. 281 of 1967.

Under penalty of perjury, I certify that the number of withholding exemptions claimed on this certificate does not exceed the number to which I am entitled. If claiming exemption from withholding, I certify that I anticipate that I will not incur a Michigan income tax liability for this year.

Date

11. Federal Employer Identification Number

Enter the number of personal and dependent exemptions you are claimingAdditional amount you want deducted from each pay(if employer agrees)

6.7.

8.a.b.c.

EMPLOYEE:If you fail or refuse to file this form, youremployer must withhold Michigan income taxfrom your wages without allowance for anyexemptions. Keep a copy of this form for yourrecords.

INSTRUCTIONS TO EMPLOYER:Employers must report all new hires to the Stateof Michigan. Keep a copy of this certificate withyour records. If the employee claims 10 or morepersonal and dependent exemptions or claims astatus exempting the employee fromwithholding, you must file their original MI-W4form with the Michigan Department of Treasury.Mail to: New Hire Operations Center, P.O. Box85010; Lansing, MI 48908-5010.

$ .00

Employer: Complete lines 10 and 11 before sending to the Michigan Department of Treasury.10. Employer's Name, Address, Phone No. and Name of Contact Person

4. Driver License Number

6.

7.

A Michigan income tax liability is not expected this year.Wages are exempt from withholding. Explain: _______________________________________________________Permanent home (domicile) is located in the following Renaissance Zone: _________________________________

Yes

No

If Yes, enter date of hire . . . .

If you hold more than one job, you may not claim the sameexemptions with more than one employer. If you claim thesame exemptions at more than one job, your tax will be underwithheld.

Line 7: You may designate additional withholding if you expect to owe more than the amount withheld.

Line 8: You may claim exemption from Michigan income tax withholding ONLY if you do not anticipate a Michigan incometax liability for the current year because all of the followingexist: a) your employment is less than full time, b) yourpersonal and dependent exemption allowance exceeds yourannual compensation, c) you claimed exemption from federalwithholding, d) you did not incur a Michigan income tax liabilityfor the previous year. You may also claim exemption if yourpermanent home (domicile) is located in a Renaissance Zone.Members of flow-through entities may not claim exemptionfrom nonresident flow-through withholding. For moreinformation on Renaissance Zones call the Michigan Tele-HelpSystem, 1-800-827-4000. Full-time students that do not satisfyall of the above requirements cannot claim exempt status.

Web SiteVisit the Treasury Web site at:www.michigan.gov/businesstax

INSTRUCTIONS TO EMPLOYEEYou must submit a Michigan withholding exemption

certificate (form MI-W4) to your employer on or before the datethat employment begins. If you fail or refuse to submit thiscertificate, your employer must withhold tax from yourcompensation without allowance for any exemptions. Youremployer is required to notify the Michigan Department ofTreasury if you have claimed 10 or more personal anddependent exemptions or claimed a status which exempts youfrom withholding.

You MUST file a new MI-W4 within 10 days if your residencystatus changes or if your exemptions decrease because: a)your spouse, for whom you have been claiming an exemption,is divorced or legally separated from you or claims his/her ownexemption(s) on a separate certificate, or b) a dependent mustbe dropped for federal purposes.

Line 5: If you check "Yes," enter your date of hire (mo/day/year).

Line 6: Personal and dependent exemptions. The total number of exemptions you claim on the MI-W4 may not exceed thenumber of exemptions you are entitled to claim when you fileyour Michigan individual income tax return.

If you are married and you and your spouse are both employed, you both may not claim the same exemptions witheach of your employers.

1. Social Security Number 2. Date of Birth

City or Town State ZIP Code

I claim exemption from withholding because (does not apply to nonresident members of flow-through entities - see instructions):

3281, MI Dept of Treasury (10-97)

STATE OF MICHIGAN

NEW HIRE REPORTING FORM

PLEASE TYPE OR PRINT NEATLY IN UPPER-CASE LETTERS AND NUMBERS, USING DARK, BALL-

POINT PEN

EMPLOYEE INFORMATION:

Social Security Number:

Name: First M.I.

Last

Address:

City: State : MI Zip Code:

EMPLOYER INFORMATION:

Federal EIN: 46-4318733

Employer Name: A. M. Herbst, Inc.

Address: 215 E. Big Beaver Rd., Ste. 150

City: Troy State: MI Zip Code: 48083

OPTIONAL INFORMATION:

Employee Date of Hire: Date of Birth:

Employee Driver’s License No.:

Reports must be submitted within 20 calendar days of date of hire.

Send Reports to: Michigan New Hire Operations Center

Fax: (517) 886-9190

Questions: Call 1-800-524-9846

An A.M. Herbst Company

New Employee Information Sheet

Name: __________________________________________________

Address: ________________________________________________

Phone: __________________________ Email: __________________________

Fax this form, along with the following completed forms, to Cech, Rosso, &

Company (586) 726-8599

• W-4

• MI-W4

• Employee Information for Direct Deposit

• Intercept Authorization

Troy Office Livonia Office

215 E. Big Beaver Rd. 32232 Schoolcraft Rd.

Suite 150 Suite C-1

Troy, MI 48083 Livonia, MI 48150

troymm@merrymaids.net livonia@merrymaids.net