Employment Eligibility Verification

Department of Homeland SecurityU.S. Citizenship and Immigration Services

USCIS

Form 1-9

OMB No. 1615-0047

Expires 03/31/2016

•START HERE. Read instructions carefully before completing this form. Theinstructions mustbe available during completion of this form.ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify whichdocument(s) they will accept from an employee.The refusal to hirean individual because the documentation presented has a futureexpiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation (Employees must complete andsign Section 1ofForm 1-9 no laterthan thefirst day ofemployment, butnotbeforeaccepting a job offer.)

Last Name (FamilyName) First Name (Given Name) Middle Initial Other Names Used (ifany)

Address (Street Number and Name) Apt. Number City or Town State Zip Code

Date of Birth (mm/dd/yyyy) U.S. Social Security Number

ZOLZZE-mail Address Telephone Number

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents inconnection with the completion of this form.

I attest, under penalty of perjury, that I am (check one of the following):

O Acitizen ofthe United States

• Anoncitizen national ofthe United States (See instructions)

• Alawful permanent resident (Alien Registration Number/USCIS Number):

O An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy)(See instructions)

Some aliens may write "N/A" in this field.

Foraliens authorized to work, provide your Alien Registration Number/USCIS Number OR Form 1-94Admission Number:

1. Alien Registration Number/USCIS Number:

OR

2. Form I-94 Admission Number:

Ifyou obtained your admission number from CBP in connection with your arrival in the UnitedStates, include the following:

Foreign Passport Number:

Countryof Issuance: 1

Some aliens may write "N/A" on the Foreign Passport Number and Country of Issuance fields. (See instructions)

3-D Barcode

Do Not Write in This Space

Signature of Employee: Date (mm/dd/yyyy):

Preparer and/or Translator Certification (To becompleted and signedifSection 1isprepared bya person other than theemployee.)

Iattest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge theinformation is true and correct

Signature of Preparer or Translator: Date (mm/dd/yyyy):

Last Name (Family Name) First Name (Given Name)

Address (Street Number and Name) City or Town State Zip Code

dp Employer Completes Next Page ^p

Form 1-9 03/08/13 N Page 7 of 9

Section 2. Employer or Authorized Representative Review and Verification *(Emptoyers ortheirauthorizedrepresentativemust complete and sign Section 2 within 3 business days of the employees first day of employment Youmustphysically examineone documentfrom ListA ORexaminea combination of one document from ListB and one documentfrom ListCas listedonthe "Lists of AcceptableDocuments" on the nextpage of thisform. Foreach documentyou review, recordthe following information: documenttitle,issuing authority, document number,and expiration date, if any.)

Employee Last Name, First Name and Middle Initial from Section 1:

List A OR

identity and Employment Authorization

ListB

Identity

AND List C

Employment Authorization

Document Title: \1 Document Title: Document Title:

Issuing Authority: i Issuing Authority: Issuing Authority:

Document Number.j

Document Number: Document Number:

Expiration Date (ifany)(mm/dd/yyyyY. 'I

Expiration Date (ifany)(mm/dd/yyyy): Expiration Date (ifany)(mm/ddfyyyyY.

Document Title: i!

IssuingAuthority: jj

Document Number:

Expiration Date (ifany)(mm/ddfyyyy): ji

i

3-D Barcode

Do Not Write in This SpaceDocument Title: \

Issuing Authority: \

Document Number

Expiration Date (ifany)(mm/dd/yyyy):

Certification

I attest under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) theabove-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge theemployee is authorized to work in the United States.

The employee's first day of employment (mm/dd/yyyy). (See instructions forexemptions.)

Signature of Employer or Authorized Representative Date (mm/dd/yyyy) Title of Employer or Authorized Representative

Last Name (FamilyName) First Name (GivenName) Employer's Business or Organization Name

Employer's Business or Organization Address (Street Number and Name) City or Town State Zip Code

Section 3. Reverification and Rehires (To be completed andsignedbyemployer orauthorized representative.)A. New Name Ofapplicable) Last Name (Family Name) First Name (Given Name) Middle Initial IB. Date of Rehire (ifapplicable) (mm/dd/yyyy):

C. Ifemployee's previous grant of employment authorization has expired, provide the information for the document from List A or List C the employeepresented that establishes current employment authorization in the space provided below.

Document Title: Document Number: Expiration Date (ifany)(mm/dd/yyyyY.

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and ifthe employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.

Signature of Employer or Authorized Representative: Date (mm/dd/yyyy): Print Name of Employer or Authorized Representative:

Form 1-9 03/08/13 N Paee 8 of 9

Form W-4 (2014)Purpose. Complete Form W-4 so that your employercan withhold the correct federal income tax from yourpay. Consider completing a new Form W-4 each yearand 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 formto validate it. Your exemption for 2014 expiresFebruary 17, 2015. See Pub. 505, Tax Withholdingand Estimated Tax.

Note. Ifanother person can claim you as a dependenton his or her tax return, you cannot claim exemptionfrom withholding if your income exceeds S1,000 andincludes more than $350 of unearned income (forexample, interest and dividends).

Exceptions. An employee may be able to claimexemption from withholding even if the employee is adependent, if the employee:

• Is age 65 or older,

• Is blind, or

• Willclaim adjustments to income; tax credits; oritemized deductions, on his or her tax return.

The exceptions do not apply to supplemental wagesgreater than $1,000,000.

Basic instructions. If you are not exempt, completethe Personal Allowances Worksheet below. Theworksheets on page 2 further adjust yourwithholding allowances based on itemizeddeductions, certain credits, adjustments to income,or two-earners/multiple jobs situations.

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.

Head of household. Generally, you can claim headof household filing status on your tax return only ifyou are unmarried and pay more than 50% of thecosts of keeping up a home for yourself and yourdependent(s) or other qualifying individuals. SeePub. 501, Exemptions, Standard Deduction, andFiling Information, for information.

Tax credits. You can take projected tax credits into accountin figuring your allowablenumber of withholding allowances.Credits for child or dependent care expenses and the childtax credit may be claimed using the Personal AllowancesWorksheet below. See Pub. 505 for information onconverting your other credits into withholdingallowances.

Nonwage income. If you have a large amount ofnonwage income, such as interest or dividends,consider making estimated tax payments using Form1040-ES, Estimated Tax for Individuals. Otherwise, youmay owe additional tax. If you have pension or annuityiincome, see Pub. 505 to find out if you should adjustyour withholding on Form W-4 or W-4P.

Two earners or multiple jobs. If you have aworking spouse or more than one job, figure thetotal number of allowances you are entitled to claimon all jobs using worksheets from only one FormW-4. Your withholding usually will be most accuratewhen all allowances are claimed on the Form W-4for the highest paying job and zero allowances areclaimed on the others. See Pub. 505 for details.

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

Check your withholding. After your Form W-4 takeseffect, use Pub. 505 to see how the amount you arehaving withheld compares to your projected total taxfor 2014. See Pub. 505, especially if your earningsexceed $130,000 (Single) or S180,000 (Married).Future developments. Information about any futuredevelopments affecting FormW-4 (such as legislationenacted after we release it)will be posted at www.irs.gov/w4.

Personal Allowances Worksheet (Keep for your records.)Enter "1" for yourself if no one else can claim you as a dependent A

(• You are single and have only one job; or

• 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 or morethan 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.• Ifyour total income will be less than $65,000 ($95,000 if married), enter "2" for each eligible child; then less "1" if youhave three to six eligible children or less "2" if you have seven or more eligible children.

• If your total income will be between $65,000 and $84,000 ($95,000and $119,000 ifmarried), enter "1" for each eligiblechild ... 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

Form

Department of the TreasuryInternal Revenue Service

( • Ifyou plan to itemize or claim adjustments to income and want to reduce your withholding, see the DeductionsFor 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 combinedworksheets earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 tothat apply. avoid having too little tax withheld.

• If neither of the above situations applies, stop here and enter the numberfrom line Hon line5 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 OMB No. 1545-0074W-4• 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. 14Your first name and middle initial Last name

Home address (number and street or rural route)

City or town, state, and ZIP code

2 Your social security number

3 I I Single I I Married I I Married, but withhold at higher Single rate.Note. Ifmarried, but legallyseparated, 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 1-800-772-1213 for a replacement card. • P

5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2)6 Additional amount, if any, you want withheld from each paycheck

7 I claim exemption from withholding for 2014, and Icertify 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 Iexpect a refund of all federal income tax withheld because I expect to have no tax liability.Ifyou meet both conditions, write "Exempt" here I

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.)

Employer's name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.)

For Privacy Act and Paperwork Reduction Act Notice, see page 2.

9 Office code (optional)

Cat. No. 10220Q

Date^

10 Employer identification number (EIN)

Form W-4 (2014)

Form W-4 (2014)

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 2014 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state

and local taxes, medical expenses in excess of 10% (7.5% ifeither you or your spouse was bom before January 2,1950)of yourincome, and miscellaneous deductions. For 2014, you may have to reduce your itemized deductions if your income isover $305,050andyou aremarried filing jointly orarea qualifying widow(er); $279,650 ifyou arehead ofhousehold; $254,200 ifyou aresingle andnothead ofhousehold ora qualifying widow(er); or$152,525 ifyou aremarried filing separately. SeePub. 505fordetails .... 1

{$12,400 ifmarried filing jointly or qualifying widow(er) 1$9,100 if head of household f 2$6,200 ifsingle or married filing separately '

3 Subtract line 2 from line 1. If zero or less, enter "-0-" 3

4 Enter an estimate of your 2014 adjustments to income and any additional standard deduction (see Pub. 505) 45 Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to

WithholdingAllowances for 2014 Form W-4 worksheet in Pub. 505.) 5

6 Enter an estimate of your 2014 nonwage income (such as dividends or interest) 6

7 Subtract line 6 from line 5. If zero or less, enter "-0-" 7

8 Divide the amount on line 7 by $3,950 and enter the result here. Drop any fraction 89 Enter the number from the Personal Allowances Worksheet, line H, page 1 9

10 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 (orfrom line10 above ifyou used the Deductions and Adjustments Worksheet)

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"

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

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 tofigure the additional withholding amount necessary to avoid a year-end tax bill.

4 Enter the number from line2 of this worksheet 45 Enter the number from line1 of this worksheet 56 Subtract line 5 from line 4

7 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 . .

9 Divide line 8 by the number of pay periods remaining in 2014. For example, divide by 25 ifyou are paid every twoweeks and you complete this form on a date in January when there are 25 pay periods remaining in 2014. Enterthe result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck

Table 1 Table 2

9 $

Page 2

Married Filing Jointly All Others Married Filing Jointly All Others

Ifwages from LOWESTpayingjob are-

$0

6,00113,00124,001

26.00133,00143.00149,00160.00175.00180.001

100,001115,001130.001140,001150.001

- $6,000- 13.000- 24.000- 26,000- 33,000- 43.000- 49.000- 60.000- 75.000

- 80,000- 100.000- 115.000- 130.000- 140.000- 150.000and over

Enter on

line 2 above

0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

Ifwages from LOWESTpaying job are-

$06.00116.00125.00134.00143.00170.00185,001110.001125.001140.001

- $6,000- 16.000- 25,000- 34,000- 43.000- 70.000- 85.000

- 110.000- 125.000- 140,000and over

Enter on

line 2 above

0

1

2

3

4

5

6

7

8

9

10

Privacy Act and Paperwork Reduction Act Notice. We ask for the informationon thisformto carryout the InternalRevenuelaws of the UnitedStates. InternalRevenueCodesections3402(f)(2) and 6109and theirregulations require youto provide this information; youremployer uses it to determineyourfederal incometax withholding. Failure to provideapropertycompleted form will result in your being treated as a singleperson who claims nowithholding allowances; providing fraudulent informationmaysubject you to penalties. Routineuses ofthis information includegivingit to the Department of Justice for civil and criminallitigation; to cities, states, the Districtof Columbia, and U.S. commonwealths and possessionsfor use inadministering their tax laws; and to the Departmentof Healthand HumanServicesforuse inthe National Directory of NewHires. We mayalso disclose this information to othercountriesunder a tax treaty, to federal and state agencies to enforce federal nontax criminallaws,or to federal lawenforcementand intelligenceagencies to combat terrorism.

Ifwages from HIGHESTpaying job are-

$074.001130,001200.001355,001

$74,000130.000200.000355.000400.000

400,001 and over

Enter on

line 7 above

$590

9S0

1,1101.3001.3801.560

Ifwages from HIGHESTpaying job are—

$037.00180,001175.001

$37,00080.000175.000385.000

385,001and over

Enter on

line 7 above

$590

990

1,1101.3001.560

Youare not required to providethe information requested on a formthat is subject to thePaperworkReductionAct unless the formdisplays a validOMBcontrol number. Books orrecords relatingto a formor its instructions must be retained as longas their contents maybecome materialin the administrationof any InternalRevenue law.Generally, tax returns andreturninformation are confidential, as required by Code section 6103.

Theaverage timeand expenses requiredto complete and filethis formwill varydependingon individual circumstances. Forestimated averages, see the instructionsforyour income taxreturn.

Ifyouhavesuggestions for making this formsimpler,we wouldbe happyto hear fromyou.See the instructions for your income tax return.

PRT Employment Application

1understand that as an employee of Personnel Response Team, Imay not accept a temporary position with any client Personnel ResponseTeam until (1) that client has paid Personnel Response Team a placement fee of $2,500.00 or (2) I have completed 6 months or 1,000hours of employment with that client through Personnel Response Team.

NAME:

ADDRESS:

Last First Middle

PHONE:

Street City State Zip

iff

Personnel Response Teamwill conduct a search on the National Sex Offender Public Registry'- Ifyou are listed on this web site,

Personnel Response Team will not employ you. Isyour name listed on this registry? __ Yes__ No

Check box in front of each operation or machine "inor on which"you have had actual working experience.

GENERAL LABOR

__ Air hammer

__ Furniture moving

__ Load & unload

trucks

__ Assembly

__ Hand glass cutter

__ Mailing

__ Stuffing

__ Collating

__ Injectionmolding

__ Packaging

__ Custodial

__ Landscaping__ Shipping &receiving

__ Electronic assembly

__ Laundry

__ Stapling

SKILLED LABOR

__ Brush painter

__ Soldering__ Cabinet maker

__ Spray painter

__ Carpenter

__ Wood cutting

__ Cement __ Sheet metal

WELDING

— Mig.

__ Journeyman- Tig.__ O/set printing

__ Arch.

__ Schematics

__ Blueprint reading Drill press operator

MOTOR VEHICLES/HEAVY EQUIPMENT__ Class I

__ Crane operator

__ Class II

__ Earth mover

__ Class III

__ Payloader__ Backhoe

__ Roller operator

__ Bulldozer operator

MACHINE TOOLS

__ Mill

__ Bridgeport

__ Lathe

__ Computerized

__ Drilling

__ Surface grinding

__ Horizontal __ Vertical

If you are a skilled craftsman, list tools you now own:

I hereby state that all statements made by me in this application are true. You have my permission to investigate any of the aboveinformation.

Personnel Response Team has work available for you the next business day following your last assignment. You mustphysically report to work on time, in proper dress code and sign the sign-in sheet. Ifyou fail to do so, you will be deemed to havevoluntarily quit and may be denied unemployment benefits.

Signature Date

Jury Waiver

Personnel Response Team ("the Company") believes that juries add unnecessary expense to resolving conflicts' and are toounpredictable. Accordingly, by signing this Jury Waiver, you understanding that any lawsuit relating to your employment withthe Company, or the termination thereof, will be heard by a judge, rather than a jury, and that you expressly agree to waive anyright that you otherwise may have to a trial by jury, unless otherwise prohibited by law.I enter into the following Jury Waiver as an express condition of my employment, or continued employment, with the Company: Iunderstand and agree that this Jury Waiver includes, but is not necessarily limited to:

a. Disputes relating to my employment with the Company, including but not limited to: (1) claims of discrirninationunder federal, state, or local laws; (2) claims regarding compensation, including overtime, under federal, state, or locallaws; (3) claims regarding job assignments, transfer, promotion, demotion, disciplinary action, and/or terrnination underfederal, state, or local laws; and (4) claims regarding the application or interpretation of any of the terms of this Jury Waiver;or

b Me and another employee of the Company relating to the other employee's employment, including but not limited to:(1) claims of discrimination under federal, state, or local laws; (2) claims regarding compensation, including overtime, underfederal, state, or local laws; (3) claims regarding assignments, transfer, promotion, demotion, disciplinary action and ortermination under federal, state, or local laws; and (4) claims regarding the application or interpretation of any of the termsof this Jury Waiver.I understand and agree that the Company and I mutually waive all rights to a jury trial to resolve these disputes,which currently exist or may arise in the future, unless otherwise prohibited by law.

I understand and agree that this Jury Waiver is not an employment contract and that nothing in this Jury Waiver changes the at-will

nature of my employment relationship with the Company, and that either the Company or Imay choose to terminate my employment

at anytime forany lawful reason.

READ CAREFULLY BEFORE SIGNING - IFYOU DO NOT UNDERSTAND THE TERMS OF THIS IURY WAIVER YOU ARE RECOMMENDED

TO SEEK LEGAL ADVICE.

Ihave read this document carefully and agree to waivea trialby jury.

Date Employee Signature

Employee's Printed Name

Personnel Response Team

Date By(Company Representative)

Safety Rules

We want you to be safeon every job siteyou go to. However, we cannot be at every job site with you making sure our customerscare about safety asmuch aswe do. If you are asked to do something at ajob sitethat isdangerous, do not do it. Call us immediatelyand do what we tell you.

Ifyou are asked to work more than 6 feet affthe ground, you mustbe given equipment to protect you from falling.Ifyouare not given the equipment, do not go above ground untilyou call us for instructions.

Ifyou are asked to work in a ditch more than 4 feet deep, do not do sountilyou call us for instructions.

Working in hot temperatures is dangerous. By the time you feel thirsty or sick, it is too late. Drink a lot of cool water all day. Keeptaking restbreaks. Wear light-colored clothing made ofcotton. Do the heaviest workinthe coolest time of the day. Work in the shadewhen you can. Ifsomeone at the jobsite tells you not to do these things, stopworking and call us.

If you are working where anything could fall on your head; you mustwear ahard hat. If you donot have one, ask for one. If you ask forone and it isnot given to you,stop workingand callus.

If you are doing work thatcould involve things flying into your face oreyes, you mustwear goggles, glasses, shields, orother things likethis to protect your face andeyes. Ifyoudo not have protection, ask for it. Ifyouaskfor protection and are not given protection, stopworking and callus.

If you are doing work that could involve loud noises, you must wear earplugs, earmuffs, or other things likethis to protect yourhearing. If you do not have hearing protection, ask for it. If you ask for it and are not given it, stop working and call us. If you aredoing work that involves breathing in dust, dirt, or things other than clean air, you must wear breathingprotection. If you do nothave protection, ask for it. Ifyou ask for it and are not given it, stop workingand call us.

Ifyou are doing work that could put your fingers, hands, toes, or feet in danger, you must wear proper gloves or boots. If you donot have gloves orboots, ask for them. If you ask for them and are not given them, stop working and callus.

If you are given hard hats, gloves, eye protection, boots, vests, hearing protection, or other personal protection equipment, youwill wear them even if other workers do not. Failure to wear or use the required personal protection equipment can reduce yourworkers'compensation benefits and willget you fired for failing to follow company policy. We may givethese things to you, orthecustomermaygivethem to you.Youwill return them to the customeror to us when the workday is done. Ifyou do not return them, youagree we cantake the cost of those items out of your pay.

Employee Signature Print Name Date

Basic Rules

Workers' comp. Ifyou get hurt whileworkingforus,you must tellus at the first chance you get even ifyou do not think it is serious or donot want medical care.When you sign for your paycheck, part of what you are signing is a statement that you told us you got hurt ifinfactyoudidget hurt. Ourinsurance company might thinkyouare lying ifyouget hurt at work but do not tell us about it until later. Also, ifyou get hurt at work you cannot collect fullworkers'compensation wage loss benefits and work at the same time. Ifafter you are hurtyou return to work for someone other than us, you must tellus and the workers'compensation insurance company that you returned towork, who you are workingfor, and how much youare making. Ifyouworkwhilecollectingbenefits, fail to tell us you returned to work, orfail to tell us howmuch you are making, you may be guilty of athird degree felony punishable by up to 5years in prison and a$5,000.00fine. Ifwe find out, we will press charges.Finally, we do not put up with fraud. We fully investigate every injuryclaim we get, and ifwe findfraud you will be prosecuted.

Lying about who you are. If you he about who you are or give us fake documents, like a social security card, driver's license orimmigration papers as identification, you may be guiltyof a third degree felony punishable by up to 5 years in prison and a $5,000 fine.Ifwe find out,we willpress charges.

Work Available. You work for us day to day.Whether you are offered work depends on what our customers need each day, when youshow up to our office, what skills you have, and how reliable you are.We do not guarantee that you will be offered or get work. Ifyouhave a repeat ticket and missone day of the repeat ticket, you lose the repeat ticket.

Getting to and from the job site. How you get to and fromthe job site on timeisyourchoice. You are free to driveyour own carifyouhaveone Ifyoudo not havea car, you are free to take a taxi, public bus,or anyother public transportation available. You are free to ride with aco-worker. Ifwe have one of our own vans or buses available, you are free to take it.The choice is yours. Ifyou chooseto ride with a coworker who wants to be paid for driving you, unless otherwise prohibited by law, you authorize us to take the fee out of your paycheckand put it in the paycheckof the co-worker who droveyou.Ifyou choose to ride one of our buses or vans,unless otherwise prohibited bylaw, youauthorize us to take a nominal charge out of yourpaycheck for the service. Whichever you choose,be sure you get to the job siteon time.Asfor getting yourpaycheck, you decide whether youwant to get a paycheck the same day or wait to get it later.

Walking off Ifyou walk off the job for any reason other than because we told you to after learning of a safetyconcern, or ifyou arekicked off the job by the customer, you will be paid nummum wage regardless of what pay rate was agreed to at the start of the workdayand then onlyfor those hours that our customer says you actually worked. You might be lred, and will not be given a ticket for thatcustomer ever again.

PersonnelResponse Team isnot a storage place. We are not responsible foranythingyou leave at or around our once.

Act Respectfully. We expect you to treat our office, your co-employees, customers, and everyone else with respect while youare onour property or on the job site.Ifyou don't, we will fire you and have you trespassed from the property. At the same time,we expect you torealize that our office is not your home. Sleepingat, living on,or hanging around our office property when the office is not open will getyou fired and, possibly, arrested.

IllegalDrugs &Alcohol. Weare a drug and alcohol freeworkplace. Do not come to workunder the inOuence of alcohol or illegal drugs.Donot take or use illegal drugs, alcohol, or legaldrugs not prescribed to youby a doctorwhile working forPersonnel Response Team. Donotbuy, sell, or have illegal drugs or alcohol, or legaldrugs not prescribed to youwhile working for us. Do any of these things and you will befired.You agree that we may test you for drugs and alcohol at any time, including after any work accident. If you refuse to be testedwhen ask, you will be fired. If you fail a test for illegal drugs or alcohol, you will be fired. You can have a copy of the full PersonnelResponse Team drug free workplace policyany time by calling the Risk Department.

Takinga job with a Personnel Response Team customer.You maynot takea jobwithanyofour customers until that customerhaspaidPersonnelResponse Team a placement fee of $2,500.00 or you have completed 6 months or 1,000hours of employment with thatcustomer through Personnel Response Team.

Employee Signature PrintName Date

Arbitration Agreement

Personnel ResponseTeam Mandatory, Irrevocable &Binding ArbitrationAgreement

You have been offered employment with or are already employed by Personnel Response Team LLC. Throughout the rest of thisAgreement, Personnel Response Team LLC isreferred to as"the Company" "us", or"we." Sometimes the"we" will mean both you and us;when thishappens it will be clearwhat ismeant.

It isyour and our express intention that any andall complaints you have regarding your hiring, firing, or treatment by us, co-employees, customers, or vendors while employed with us, including though not limited to claims for compensation and benefits,claims of harassment or mscrimination of any kind as well as other intentional acts of any kind, will be presented to arbitration forresolution. You also agree thatthis agreement toarbitrate includes all claims for benefits for anywork-related injury if thestate inwhich youare injured allows for thearbitration ofsuch claims, inwhich case thearbitration process will beconducted according to thelaw ofthestatewhere the injury occurred. Furthermore, it is your and our express intention that any and all claims you have will be submitted toarbitration evenifvou choose tobringthoserlaimsaftprvouhaveleftouremployment for whateverreason. Ifyou oryour lawyer filesalawsuit, you agree that the lawsuit will give way to the arbitration required bythisagreement.

Arbitration is a way of resolving disputes without taking the disputes into the court system. The decision of the arbitrator,however, isjust as enforceable as the judgment ofa court or the verdict ofa jury. You and the Company will choose from a list ofpeoplewho are specially trained inarbitration provided to usbythe American Arbitration Association; the arbitrator will not have any connectionto us. You will have to paythe filing fee(unless prohibited bystate law), but you will not be responsible for the cost of the arbitrator. Youhave every right to be represented in the arbitration by an attorney you hire, but you will be responsible for your own attorney's feesand costs unless the law allows you to recover attorney's fees or costs in the event you win your claim. We both agree that to theextent allowed by the law, the arbitration process itself will be conducted by the American Arbitration Association and will be governedfrom beginning to end by a set of rules known as the American Arbitration Association National Rules for the Resolution ofEmployment Disputes. Ifyou want a copy of these rules, please call our Human Resources Department and a copy will be mailed to you.Your agreement to present your claims to arbitration is"mandatory" "irrevocable", and "binding." This means two things. First, the words"mandatory"and"irrevocable"mean neither you norwecanchange ourminds about agreeingto arbitration and go to courtinstead. Wehave both given up forever our rightto have a judgeor jury decide the case. Second, the word"binding"means that we both have to livewith the decision the arbitrator panel makes. Ourrights to appeal arevery, very limited and do not allow for an appeal simply because wedo not like the end result. The arbitrator will not have the right to change ouragreement to submit your claims to arbitration. Lastly, thisagreement isnot an employmentcontract;you are still employedwithus on an at-will basis.

You understand that we will not offer or continue your employment unless you sign this Agreement. Should anyprovision ofthisAgreement become invalid or unenforceable by decision of any court or act of any legislative or quasi-legislative body or entity,then such provision shallbe regarded as deleted or automatically revised to comply with such decision or act and to allow maximumenforceability of this Agreement.

Ifarbitration does ever happen between us, we both agree that the arbitration will occur in or near the city where you werelastemployed byus and that the"Arbitration Rules and Mediation Procedures" of the American Arbitration Association will apply, unlessdifferent rules are specifically set forth in this Agreement or agreed to by us. Ifa lawsuit about thisarbitration agreement is ever filed,you agree that you will not objectto or resist moving the issues to arbitration as required bythisagreement. Our agreement to arbitrateall claims isintended by both ofus to be mandatory and not permissive.

You understand that thisagreement isthe only agreement to arbitrate between you and the Company and supersedes any otherprioragreements on this subject. The arbitrator will have the authority to hear only timely asserted claims and may dismiss any claim ordispute that fails to assert a legally cognizable or timely claim. The arbitrator is not authorized to award punitive or other damages notmeasured by the prevailing party's actual damages. The arbitration proceedings and arbitrator's award shall be maintained as strictlyconfidential, except as required bya courtorderor as necessary to enforce the award and except as to the attorneys, tax advisors and yourimmediate family members.

You and the Company agree that at no time shallthis arbitration agreement ever be interpreted to allow class actions, collectiveactions, or other similar multi-party claims. In simple language, thismeans that your claims will never, ever be joined with the claims ofotherpersons. Your dispute with the Company will be resolved between you and the Company inarbitration without involving claims ofother current or formeremployees.

Ifat the beginning of or at any time during youremployment with us you signed a document agreeing not to compete with usafter your employment has ended and/or to keep confidential all information you learn while employed with us, all matters involvingthe enforcement of our rights under those agreements are not governed by this arbitration agreement

The Company Employee

Signature Signature

Title Name (Print)

Date Date

Substance Abuse Policy

Personnel Response Team is committed to a drug and alcohol free work environment. As an employee of PersonnelResponse Team:

You may not report to workwith illegal drugs, alcohol, or prescription drugs in yourbody forwhich you do not have avalidprescription.You may not take illegal drugs orprescription drugs for which you do not have a valid prescription orusealcohol during yourwork hours.

Youmaynot take, possess, sell, orbuyillegaldrugs, prescriptiondrugs for whichyoudonothaveavalid prescription, oralcohol atanytime during workhours.Youmaynot refuse to take a drug and/or alcohol test ifasked.You maynot substituteanother person's bloodorurinesample for yourownwhenyousubmitto a drugoralcohol test,andyoumaynot alter yourown by adding anysubstance.

If you violate these rules, youremployment with Personnel Response Team will be subject to termination. You are welcome to reviewthe full Drug Free Workplace Pohcy at any time you wish; simply give your supervisor a written request and a copy of the policy willbe providedto you.

Drug Testing at Personnel Response Team

As an employee of Personnel Response Team, you may be tested forthe presence of alcohol, illegal drugs, and/or prescription drugsforwhich you do not have a valid prescription. Personnel Response Team may conduct drug and/or alcohol tests in the followingsituations:

•Random Testing. A random selectionof employees will fromtime to time be tested for drugs and/or alcohol. The tests will beunannounced and you willnot have advance notice.

•For CauseTesting. When Personnel Response Teamhas a reasonable suspicion that you are using or have been usingdrugs oralcohol in violation of company policy, you will be tested for drugs and alcohol. For example, though by no means limitedto these situations, you will be drug tested if you are seen using drugs or alcohol during your work hours or on your workpremises; ifyou act like you are under the influence of drugs or alcohol during yourworkhours or on the work premises; ifyour job performance is consistently unacceptable; or if you are excessively absent fromor late getting to work.

•ON-THE-JOB ACCIDENT TESTING. IF YOU ARE INVOLVED IN AN ACCIDENT WHILE ON THE JOB AND SEEK MEDICAL CAREBECAUSE OF INJURIES YOU SUFFER IN THE ACCIDENT, YOU WILL BE TESTED FOR DRUGS AND ALCOHOL AT THETIMEYOU RECEIVE MEDICAL CARE.

IfYou RefuseTo Take A Drug And/OrAlcoholTestPersonnel Response Team drug free work place policy is not voluntary. If you wish to continue your employment with PersonnelResponse Team,

You do not havethe choice to refuseto take a drug and/or alcohol test. If you refuse, youremployment willbe terminated. Ifthe test wasrequired becauseofyourinvolvement inan on-the-jobaccident, yourrefusal will resultnot onlyin the termination of your employment butmay also result in your losing workers'compensation benefits. When you report an injury you will be reminded that you must submit toa drug and alcohol test. Ifafter being reminded of your obligation to submit to a drug and alcohol test you refuse,your employment willbe terminated.

IfYou Fail A Drug And/Or AlcoholTestFailing adrugtest means that the laboratorythat tested yourbloodorurinefoundillegal drugs,alcohol, orprescription drugsInyour system. Ifprescription drugs are found in your system, you will be asked to produce a valid prescription for those drugs toprove that you had a legal right to take them. Regardless of whatwas found in your system, if you fail a drug and/or alcohol test you will benotifed ofthat fact and given the opportunity to be retested. However, you INITIALS:

shouldbe aware that the "retest"will be done on the verysame blood or urinetaken fromyou in the first place. Ifyou decline a retest, or ifyou ask for a retest and fail again, your employment with Personnel Response Team will be terminated. If the test was requiredbecause of your involvement in an on-the-job accident, your failing the tests will result not only in the termination of your employmentbut may also result in your losingworkers'compensation benefits.

IfYou TamperWith Your Blood OrUrine SampleDo not kidyourself. The laboratories PersonnelResponse Teamuse will know if you have tampered with your blood or urine sample.Ifyou substitute someone else'sblood or urine for your own, you will get caught. Ifyou "adulterate" or put something into your bloodor urine sample, you will get caught. And when you get caught, your employment with Personnel Response Team will be terminatedand you will be deemed to have failed your drug or alcohol test.

AuthorizationAndConsent ForDrug TestingYour willingness to be tested for drugs and/or alcohol is a condition of your employment with Personnel Response Team. Submittingyourself to a drug and/or alcohol test is a condition of you receiving medical care after an on-the-job accident. By signing your namebelow, you specifically authorize any hospital, other medical care provider, laboratory, or collection site to draw your blood and/orcollect your urine for the purposes of testing the same for the presence of illegal drugs, alcohol, and/ or prescription drugs for whichyou do not have a valid prescription. By signing your name below, you specifically direct any such hospital, other medical careprovider, laboratory, and/or collection site to honor the request of Personnel Response Team, its agents, and/or its insurance companyand representatives to draw your blood and/or collect your urine and test the same for the presence of illegal drugs, alcohol, and/orprescription drugs for which you do not have a valid prescription. By signing your name below, you agree to indemnify and holdharmless any such hospital, other medical care provider, laboratory, and/ or collection site from any and all claims, demands, suits,actions, causes of action, and damages of every kind and nature whatsoever that could arise or accrue by reason of the drawing of yourblood or collectionofyoururine and the testing of the same for the presence of illegal drugs, alcohol, and/or prescriptiondrugs forwhichyou do not have a valid prescription. By signing your name below, you state your intention that your directions and consents as hereinexpressed be valid at all times and honored by all persons regardless of your physical or mental condition at the time the blood is to bedrawn or the urine collected. By signingyour name below, you also expresslyacknowledge and attest that your agreements to provideblood and/or urine samples and your authorization to Personnel Response Team to test such samples for the presence of alcohol, illegaldrugs, and/or prescription drugs for which you have no valid prescription may not be revoked by you at any time after you havereported an injuryto Personnel Response Team, regardlessofwhether you are then employed by Personnel ResponseTeam.

Authorization for Release of DrugTest InformationAS A PART OF MY EMPLOYMENT WITH PERSONNEL RESPONSE TEAM I AGREE THAT THERE IS A NEED FOR PERSONNEL RESPONSE

TEAM TO HAVE ACCESS TO INFORMATION ABOUT ANY DRUG TEST I TAKE WHILE I AM EMPLOYED WITH THEM. I AGREE THAT

THIS INCLUDES, BUT IS NOT LIMITED TO, DRUG TESTS DONE AFTER I GET HURT. I HEREBY AUTHORIZE Personnel Response TeamTO OBTAIN INFORMATION REGARDING THE DRUG TEST TO WHICH I SUBMITTED. SPECIFICALLY, I AUTHORIZE THEM TOOBTAIN THE LIST OF DRUGS I WAS TESTED FOR, A COPY OF THE FINAL,FULLY-EXECUTED CHAIN OF CUSTODY FORM, A COPYOF THE MRO REPORT, AND THE ACTUAL QUANTTTATTVE AMOUNTS FOUND IF THE TEST RESULTS WERE POSITIVE FOR ANYSUBSTANCE TESTED FOR. I AUTHORIZE PERSONNEL RESPONSE TEAM TO DISCLOSE ANY OF THIS INFORMATION TO ANY

CLIENT OF PERSONNEL RESPONSE TEAM OR ANY OTHER PARTY INVOLVED IN ANY WAY WITH A POST-ACCIDENT DRUG TEST.

THIS AUTHORIZATION WILL LAST FOR 10 YEARS AFTER EACH DRUG TEST I TAKE.

Employee's Signature PrintName Date

WitnessSignature Print Name Date

Conditional Employment Medical QuestionnaireIherewith understand that Personnel Response Team, has offered mea job conditional upon my completing this medical questionnaire,and ifrequested, undergoing a medical examination. It ismy understanding that only those applicants for employment who meet thisemployer's physical and psychological criteria for the job, with or without reasonable accommodations, will be qualified to receiveconfirmed offers ofemployment and canbeginworking.

YES NO

1.During the past five (5) years have you ever:

A. Been treated foror told that you have anysickness or injury?

B. Beenexaminedby or treated by a physician, or specialist?

C. Been ina hospital, sanitarium or other institution for observation, diagnosis, treatment oran operation. Ifyes, name the doctor

D. Been advised to have anyhospital, clinical or other treatment?

E. Are you unable to perform certain body motions or assume certain body positions?

F. Have you ever had an injuryto your back or neck?

G. Have you had any operations?

YES NO

2.Do you have or ever had:

A. Any permanent physical condition

B. BackSurgery

C. Heart Trouble

D. Diabetes

E. Knee Injury

F. Dizziness / Fainting Spells

G. Hernia/Rupture

H. Epilepsy/Seizures

I. Back PainWhen Lifting

J. Head Injury

Ifanswer isYES to any of the above listed items, explain in detail:

MEDICAL RECORDS AND OTHER INFORMATION: I authorizeanyphysician, medical practitioner, hospital, clinic or other health facility, oremployer to release any and allmedical and non-medical information in its possession about me to myemployer, his insurance carrier,or its legal representative. Medical information means all information in the possession of or derived from providers of health careregarding the medical history, mental or physical condition or treatment of me. I know that I may request and receive a copy of thisauthorization. Iagree that a photocopy of thisauthorization shall be as valid as the original.

Employee's Signature Print Name Date

Witness Signature Print Name Date

Authorization for release of Health Information

Name:

DOB:

SSN:

By signing below, I hereby authorize each and every health care provider by whom I may be evaluated or treated in connectionwith any claim under any state or federal law for workers' compensation benefits to disclose to my representative of and theirworkers' compensation insurance carrier (collectively "Authorized Persons") for the purpose of determining coverage or compensabilityunder the governing state of federal law, any and all health information related to my medical conditions or illnesses, injuries,diagnoses, and prognoses, and all medical treatment provided to me, as well as any restrictions on my ability to perform my job. Inaddition, this information mayidentify any special requirementsrelatedto myworkenvironmentas a resultof mymedical condition. Thisinformation may also be shared with AuthorizedPersonsin connectionwithanyretum-to-work program they may haveor forcertilcationofleaveunder the Family and Medical Leave Act ("FMLA"). I hereby authorize all Authorized Persons to disclose all such information toother parties as necessary to investigate, evaluate, and make decisions regarding coverage or compensability of any workers'compensationclaim I assert, and all such other parties shall be deemed to be "Authorized Persons"as contemplated herein.

I authorize all Authorized Persons examine and copy, or to obtain copies under their request, any and all diagnostic images, hospitaland clinic records regarding my physical or mental conditions, diagnoses, prognoses, or treatments, and to communicate directlywitheach and every of my health care providers directly regarding my care. I understand that all Authorized Persons will be responsible foranycosts incurred in obtaining these records.

I understand that this information and these records may also include information on diagnosis/treatment related to psychiatric orpsychological conditions, drug or alcohol abuse, acquired immune deficiency syndrome (AIDS), or HIV status. I understand and agreethat the information, if any, pertaining to such diagnosis/treatment described above maybe released.

I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment;however, it may impact coverage under workers' compensation. I understand that I mayrevoke this authorization in writing at anytime by notifying the Risk ManagementDepartment of Personnel ResponseTeam at 30480 US Hwy 19NPalm Harbor FL 34684,but if Ido, it will not have any effect on actions Personnel Response Team has taken in reliance on this authorization prior to receiving therevocationincludingas to recordsrequested beforebut not received by the time of receipt of notice of revocation.

I understand that some of the information and records released may be subject to re-disclosure by some recipients and may nolonger be protected by federal and state privacy rules related to health information. I agree that this authorization is valid for five(5) years from the date ofmy signature.

Employee Signature Print Name Date

Background Investigation Release Form

In connection with your application for employment with Personnel Response Team you understand that consumer reports or

investigative consumer reports which maycontain public record information maybe requested ormadeon youincluding consumer credit,

criminal records, driving record, education, prior employment verification, workers compensation claims and/or others. These reports will

include information from various Federal, State, local and other agencies which contain your past activities. By signing this form you

consent to the investigation of all information.

By signing below, you authorize any party or agency contacted by Personnel Response Team to furnish the above-mentioned

information. You further authorize Personnel Response Team to obtain any of the above-mentioned reports at any time during your

employment. You also agree that a fax or photocopy of thisauthorization with your signature be accepted with the same authority as

the original.

You have the right to make a request of the background-reporting agency, upon proper identilcation and the payment of any

permissible fees, for the information inits files on you at the time of your request.

You authorize andrequest, without anyreservation, anypresentorformer employer, school, police department, lnancialinstitution, division

of motor vehicles, consumer reporting agencies, or other persons or agencies having knowledge about you to furnish the background

reporting agency with any and allbackground information in their possession regarding you, for Personnel Response Team to evaluate

youremployment qualifications.

INTIALS

Background Investigation ReleaseForm

TO BE COMPLETED BY APPLICANT

PRINT NAME:

CURRENT ADDRESS:

Street

Apt#

State

City.

Phone Number

Zip.

PREVIOUS ADDRESS: (If less than 2 Years atCurrent)Street

Apt#_

State

City.

Zip.

The following is for identification purposes to perform background check:

Date of Birth (MM/DD/YYYY):_/_ / Race:

Other or Former Name Gender

SS# LIC#&ST

TO BE COMPLETED BY PERSONNEL RESPONSE TEM PERSONNEL ONLY

Date / /_

REQUESTED BY:

Name

Corporate Payroll. Client Request.

Title

Reports Requested (Please check space or spaces)

Criminal MVR-Driving History State

Position Applicant is Applying for:

Location Signature.

Federal Other

Workplace Fairness Policy

Personnel Response Teamprovides equalopportunity for employment to all applicants and employees. Wedemand that our work environment be fair, respectfuland free fromdiscrimination and/or harassment basedon a person's race, color, religion, sex (including sexual harassment), age, pregnancy, ethnic or nationalorigin, disability, veteran status, marital status, sexual orientation, union affiliation or other protectedcategory.

This Policy Applies to EveryoneIt is our policy to treat all applicants and employees who work for us fairly. We do not put up with anytype ofharassment or discrimination, whether bysupervisors, coworkers or other persons withwhom you come intocontact at the worksite. You should report allincidents of harassment or discrimination, regardless ofwho isdoing the discrimination or harassment.

Reporting A ComplaintIf you believe you are being harassed or discriminated against you should tell the offender to stop. Weunderstand that this can be difficult, especially if the offender is a supervisor, someone from a differentpart of the company, or the supervisor or employee of a customer. However, you should first tell theoffender that you do not welcome or agree with the behavior and tell the person to stop. If the personcontinues to discriminate or harass you, then you should report it to the Branch Manager or AssistantManager or to their supervisor or directly to the Human Resources Department at (727) 772-1274. If theperson doing the harassing or discriminating is a PRT employee, we will conduct an investigation. If theharassment or discrimination is coming from our customer's supervisor, employee or other person on thejob site, we will immediately inform the customer of the complaint and ask that the customer conduct aninvestigation. Based on the results of the investigation, we will deal appropriately with PRT employees andinsist that our customer deal appropriately with its employees. In all cases, we will use all reasonable meansavailable to us to protect our employees from discrimination and/or harassment.

False ReportsFalse reports of harassment or discrimination can hurt innocent persons. Ifyou make a false accusation ofdiscrimination or harassment, we will fire you.

NoRetaliation

You can be sure that we will not tolerate retaliation against employees who report what they trulybelieve tobe discrimination or harassment, or who help us with any investigation of discrimination. Any employeewho believes he or she has been the victim of retaliation for reporting discrimination or harassment orhelping us with an investigation, should immediately contact the Human Resources Department. Anyonefound to have retaliated against any person who reports discrimination or harassment, or assists with aninvestigation will be disciplined up to and including termination of employment.

Workplace Fairness Policy

This will acknowledge that Ihave been given a copy of the Personnel Response Team's Workplace FairnessPolicy, including Personnel Response Team's equal employment opportunity statement and procedure forreporting a complaint and I have read and understood the contents.

Employee Signature Date

Print Name

WOTC Questionnaire

Work Opportunity Tax Credit

Personnel Response Team is participating in the WOTC (Work Opportunity Tax Credit) program offered by thegovernment. The program has been designed to promote the hiring of individuals who qualify as a member of atarget group and to provide a Federal Tax Credit to employers who hire these individuals.

This questionnaire will assist Personnel Response Team in qualifying individuals for the WOTC. This program ison a voluntary basis and will not affect any hiring decisions. Thank you for your participation.

Applicant's NameLast Name First Name

Government Identification Number:

• ID number can be any picture ID used on the 1-9.• Examples: Driver's License, State ID, INS, Passport, etc.

Please answer YES or NO to the following questions:

Middle Initial

YES NO

1. Have you ever been employed by Personnel Response Team? • •

2. Are you between the ages of 16-39?

If YES. please provide vour date of birth:

• •

3. Are you a Veteran of the U.S. Armed Forces? (If NO, go to Question # 4)

If YES, are you a member of a family that received Supplemental Nutrition AssistanceProgram (SNAP) benefits (Food Stamps) for at least 3 months during the 15 monthsbefore you were hired?

If YES. please provide name of primary recipient

•

•

•

•

•

•

•

•

•

•

•

•

and City and State where benefits were received:

Case ID Number.

Are you a Veteran entitled to compensation for a service-connected disability?

Were you discharged or released from active duty within 1 year before you were hired?

Were you unemployed for a combined period of at least 6 months (whether or not consecutive)during the year before you were hired?

Are you a Veteran unemployed for a combined period of at least 4 weeks but less than6 months (whether or not consecutive) during the year before you were hired?

* IfyouhaveyourDD-214 readily available, pleaseprovide a copytoyour Employer *

4. Are you a member of a family that received Supplemental Nutrition Assistance Program(SNAP) (formerly Food Stamps) benefits for the 6 months before you were hired?

Did you receive SNAP benefits (Food Stamps) for at least a 3-month period within the last5 months, but you are no longer receiving them?

If YES to either question, please provide name of primary recipient

•

•

•

•

and Citv and State where benefits were received:

Case ID Number.

YES NO

5. Were you referred to an employer by a Vocational Rehabilitation Agency approved by a State? • •

OR, by an Employment Network under the Ticket to Work Program? • •

OR, by the Department of Veterans Affairs? • •

Voc Rehab Aaencv Contact Name:

Voc Rehab Aqency Phone Number.

6. Are you a member of a family that received Temporary Assistance to Needy Families (TANF)assistance for at least the last 18 months before you were hired?

• •

Are you a member of a family that received TANF benefits for any 18 months beginning afterAugust 5,1997, and the earliest 18-month period beginning after August 5, 1997, ended within2 years before you were hired?

• •

Did your family stop being eligible for TANF assistance within 2 years before you were hiredbecause a Federal or State law limited the maximum time those payments could be made?

• •

Are you a member of a family that received TANF assistance for any 9 months during the18-month period before you were hired?

• •

If YES to any question, please provide name of primary recipient

and City and State where benefits were received:

Case ID Number.

7. Were you convicted of a felony or released from prison after a felony conviction during the yearbefore you were hired?

• •

If YES. please enter date ofconviction: and date ofrelease:

Was this a Federal or a State conviction? Which State:

Department of Corrections ID Number.

Date Probation Beaan: Date Probation Exoires:

Parole Officer's Name: Parole Office's Phone Number.

8. Did you receive Supplemental Security Income (SSI) benefits for any month ending within60 days before you were hired?

• •

SS/ Contact Name:

and SS/ Contact Phone Number

I certify that the information is true and correct to the best of my knowledge. I understand that theinformation above may be subject to verification. I hereby authorize agencies, organizations, orindividuals to release requested information to MJA & Associates. I understand that this information willbe used solely for the purpose of qualifying my employer for the Work Opportunity Tax Credit program.

Signature Date

Print Name Phone Number

Form

(Rev. January 2013)

Department of the TreasuryInternal Revenue Service

8850 Pre-Screening Notice and Certification Request forthe Work Opportunity Credit

• Information about Form 8850 and its separate instructions is at www.irs.gov/form8850.

OMB No. 1545-1500

Job applicant: Fill in the lines below and check any boxes that apply. Complete only this side.

Your name Social security number •

Street address where you live

City or town, state, and ZIP code

County Telephone number

Ifyou are under age 40, enter your date of birth (month, day, year)

1 • Check here ifyou received a conditional certification from the state workforce agency (SWA) or a participating local agencyfor the work opportunity credit.

2 • Check hereif any ofthe following statementsapply to you.• I am a member of a family that has received assistance from Temporary Assistance for Needy Families (TANF) for any 9

months during the past 18 months.• I am a veteran and a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (food

stamps) for at least a 3-month period during the past 15 months.

• I was referred here by a rehabilitation agency approved by the state, an employment network under the Ticket to Workprogram, or the Department of Veterans Affairs.

• I am at least age 18 but not age 40 or older and I am a member of a family that:a Received SNAP benefits (food stamps) for the past 6 months, or

b Received SNAP benefits (food stamps) for at least 3 of the past 5 months, but is no longer eligible to receive them.• During the past year, I was convicted of a felony or released from prison for a felony.• I received supplemental security income (SSI) benefits for any month ending during the past 60 days.• I am a veteran and I was unemployed for a period or periods totaling at least 4 weeks but less than 6 months during the

past year.

3 D Check here ifyou are a veteran and you were unemployed for a period or periods totaling at least 6 months during the pastyear.

4 • Check here if you are a veteran entitled to compensation for a service-connected disability and you were discharged orreleased from active duty in the U.S. Armed Forces during the past year.

5 • Check here ifyou are a veteran entitled to compensation for a service-connected disability and you were unemployed for aperiod or periods totaling at least 6 months during the past year.

6 • Check here ifyou are a member of a family that:• Received TANF payments for at least the past 18 months, or• Received TANF payments for any 18 months beginning after August 5,1997, and the earliest 18-month period beginning

after August 5,1997, ended during the past 2 years, or

• Stopped being eligible for TANF payments during the past 2 years because federal or state law limited the maximum timethose payments could be made.

Signature—All Applicants Must Sign

Under penalties of perjury, I declare that I gave the above information to the employer on or before the day I was offered a job, and it is, to the best of my knowledge, true,correct, and complete.

Job applicant's signature • Date

For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 22851L Form 8850 (Rev. 1-2013)

Form 8850 (Rev. 1-2013) Page 2

For Employer's Use Only

Employer's name Personnel Response Team Telephone no. 727-772-1274 EIN^ 27-3698395

Street address 30846 US 19 N.

City or town, state, and ZIP code Palm Harbor, FL 34684

Person to contact, if different from above MJA & Associates Telephone no. 951-272-8294

Street address 2279 Eagle Glen Pkwy.,# 112-217

City or town, state, and ZIP code Corona, CA 92883

If, based on the individual's age and home address, he or she is a member of group 4 or 6 (as described under Members ofTargeted Groups in the separate instructions), enter that group number (4 or 6) •

Date applicant:

Gaveinformation

Wasoffered job

Washired

Startedjob

Under penalties of perjury, I declare that the applicant provided the information on this form on or before the day a job was offered to the applicant and that theinformation I have furnished is, to the best of my knowledge, true, correct, and complete. Based on the information the job applicant furnished on page 1,1believe the individual is a member of a targeted group. I hereby request a certification that the individual is a member of a targeted group.

Employer's signature •

Privacy Act andPaperwork ReductionAct Notice

Section references are to the InternalRevenue Code.

Section 51(d)(13) permits a prospectiveemployer to request the applicant tocomplete this form and give it to theprospective employer. The informationwillbe used by the employer tocomplete the employer's federal taxreturn. Completion of this form isvoluntary and may assist members oftargeted groups in securing employment.Routine uses of this form include givingit to the state workforce agency (SWA),which will contact appropriate sourcesto confirm that the applicant is amember of a targeted group. This formmay also be given to the InternalRevenue Service for administration ofthe Internal Revenue laws, to theDepartment of Justice for civil and

Title

criminal litigation, to the Department ofLabor for oversight of the certificationsperformed by the SWA, and to cities,states, and the District of Columbia foruse in administering their tax laws. Wemay also disclose this information toother countries under a tax treaty, tofederal and state agencies to enforcefederal nontax criminal laws, or tofederal law enforcement and intelligenceagencies to combat terrorism.

You are not required to provide theinformation requested on a form that issubject to the Paperwork Reduction Actunless the form displays a valid OMBcontrol number. Books or recordsrelating to a form or its instructions mustbe retained as long as their contentsmay become material in theadministration of any Internal Revenuelaw. Generally, tax returns and returninformation are confidential, as requiredby section 6103.

Date

The time needed to complete and filethis form will vary depending onindividual circumstances. The estimated

average time is:

Recordkeeping 6 hr., 27 min.

Learning about the lawor the form 30 min.

Preparing and sending this formto the SWA 37 min.

If you have comments concerning theaccuracy of these time estimates orsuggestions for making this formsimpler, we would be happy to hear fromyou. You can write to the InternalRevenue Service, Tax ProductsCoordinating Committee,SE:W:CAR:MP:T:M:S, 1111 ConstitutionAve. NW, IR-6526, Washington, DC20224.

Do not send this form to this address.Instead, see When and Where To File inthe separate instructions.

Form 8850 (Rev. 1-2013)

MJA % *.

SXtt#IfXJ(U

2279 Eagle Glen Pkwy., #112-217Corona, CA 92883

(951)272-8294

WOTC Instructions

Make sure every applicant is given a WOTC Questionnaire and 8850 Form

WOTC Questionnaire: (To be completed by applicant)

> Please make sure applicant provides State ID number on Page 1 ofQuestionnaire

> Applicant must complete and sign page 2 of the WOTC Questionnaire

8850 Form: (To be completed by applicant)

> Applicant must complete and sign page 1 of the 8850 form

> Page 2 of the 8850 Form is pre-printed. No additional information is requiredfrom employer. No signatures or dates are necessary.

New Hire Information Sheet: (To be completed by employer)

> On the employee's first day of work please complete the New HireInformation Sheet

At the end of each week please forward the following for each new hire:

a WOTC Questionnairea 8850 Form

• New Hire Information Sheet

To:

MJA & Associates

Attn: Marcel Abandonato

2279 Eagle Glen Pkwy., #112-217Corona, CA 92883

• If you have any questions or comments contact Marcel Abandonato atmarcel@mja-associates.com or (951) 272-8294.

MJA & AssociatesSpecializing in Government TaxIncentives

Work Opportunity Tax Credit (WOTC)

*** Employer Use Only ***

NEW HIRE INFORMATION SHEET

On the employee's first day ofwork please provide the following information:

Name:

Job Title:

Start Date:

Pay Rate:

Government Identification Number:

ID number can be any picture ID card used on the 1-9.Examples: Driver License, State ID, INS, Passport, etc.

Forward these three pieces of information

• WOTC Questionnaire• 8850 Form

• New Hire Information Sheet

To:

MJA & Associates

Attn: Marcel Abandonato

2279 Eagle Glen Pkwy., #112-217Corona, CA 92878

If you have any questions please contact Marcel at (951) 272-8294or marcel^/ mia-associates.com.