College Works Painting

PAINTER PAYROLL INFORMATION

Intern : Address: State: ) Email:
/
MO DAY

Division:

Employee Name: City: Phone: (

Zip Code:

If under 18 years old, state birthdate and age: Date Painter Hired:
MO

/
YEAR

Age:

/
DAY

/
YEAR

Social Security Number #: Emergency Contact:

Relationship: Phone:

Efficiency Bonus Rate per unit (as explained on the following page): $ per unit (not including discretionary bonus)

There is a discretionary bonus for painters who perform at a satisfactory level and stay until the date stated below. This is a bonus based on performance and is awarded at the discretion of the Intern. In addition to your wage, $1.00 will be put into a fund for every hour paid through the payroll service for each painter. Those who stay working until at least 09/30/2011 and perform at a satisfactory level (in the sole opinion of the Intern), will be paid this bonus at the end of October. Those painters who do not work through this date or perform at a satisfactory level will not receive this discretionary bonus. Although you work for College Works Painting, your Intern is responsible for the operation of the branch. As a paid service to the Intern, College Works Painting utilizes a payroll service to generate properly prepared paychecks for painters.

X
(PAINTER) I UNDERSTAND AND VOLUNTARILY AGREE TO ALL OF THE TERMS OF EMPLOYMENT DESCRIBED ABOVE.

X
(INTERN) ALL OF THE TERMS OF EMPLOYMENT DESCRIBED ABOVE HAVE BEEN SATISFACTORILY EXPLAINED TO THE PAINTER.

PAINTER REMUNERATION
Welcome to College Works Painting's team of hardworking, quality painters. The following is the method that you will be compensated by as an employee for our organization. Pay Procedures: The manner of compensation you will receive as an employee of College Works Painting is based on efficiency performance in relation to budgeted labor units. Under this system, the Intern of the job will budget a certain amount of labor units for the job to be performed. You will be paid according to this budget regardless of how long it actually takes to complete the job. (Of course all minimum wage and overtime laws will be strictly adhered to). College Works Painting has spent years developing an estimating system that produces fair and accurate labor budgets for our painters to work from, so if the proper effort and motivation is there, you should be able to "beat" the budgets consistently. The following are our policies and examples to help you better understand our system. Every painter must fill out an employee time sheet and performance pay computation sheet on a daily basis as shown on the example on the following page. The only earnings you are guaranteed are minimum wage, regulated by your state of employment, which is paid per hour, for every hour you work with our company. The average earnings for painters whom consistently beat the job labor budgets historically have been between $8.00 and $10.00 per hour. One important policy we have is that any painter who earns only minimum wage for two consecutive pay periods will be subject to disciplinary action up to and including termination. All overtime laws will be strictly adhered to. Overtime for painters is when a painter works over 40 hours in a scheduled workweek. You may be asked to work an alternative schedule, for example: 4 days at 10 hours each. By signing below you are endorsing this alternative workweek as hours not classified as over time. College Works Painting considers a workweek to be from Monday to the following Sunday. Overtime is paid at time and one-half the rate of minimum wage. This varies by state. All overtime work must be authorized by a College Works Painting District Manager in writing before any overtime is worked in order to receive pay for such work. Any questions or disputes you may have about your compensation must be directed to the corporate offices at 1-888-450-9675 first for immediate correction or resolution. Efficiency Bonus Rate: Each painter will be quoted an efficiency bonus rate by their Intern when they are hired. This is the rate you will receive for all efficiency bonus units earned according to our system. You will receive either minimum wage or the efficiency bonus for each work week, whichever is higher, and if the minimum wage is earned for 2 consecutive periods, you will be subject to termination. Company Objectives: To build and maintain an exceptional reputation of professionalism and integrity in how we deal with customers, employees, and the general public. Dress Code: Painters and crew chief are required to wear the CWP uniform at all times on the job site.
Example: The labor unit budget will stay the same regardless of how long it takes to do the job. If a job estimated at 100 units is done in 80 hours, 100 units will be paid. If the same job is done in 120 hours, 100 units will be paid. For example: Crew #1 has 1 Crew Chief and 2 painters. They complete the 100 unit job in 80 hours: A. Budgeted Units B. Total Hours Worked C. A B (efficiency factor) 1.25 100 80

Let's assume that the crew chief spent 30 hours on the job, while the painters spent 35 and 15 hours, respectively: Total Hours Worked x Efficiency Factor Joe Brown (Crew Chief) Bob Green (Ptr #1) Sam Slick (Ptr #2) 30 hours x 35 hours x 15 hours x = Efficiency Units Earned 1.25 1.25 1.25 = = = 37.5 43.75 18.75 x Efficiency Rate x x x Gross Efficiency Bonus Pay $6.50 $6.10 $6.10 $243.75 $266.87 $114.37

80 hours x 1.25 = 100 Joe, the Crew Chief, will earn 37.5 efficiency units times his efficiency bonus unit rate. The painters will be paid in the same way. Obviously, beating budgets is the way to avoid being paid minimum wage and earn good money. If you cannot beat the budgets, you will be Subject to termination.

I have read the above policies and example and understand the method in which I will be paid.

X Painters Name (Print)

Signed: X__________________________________________Date: Painters signature

Employee Dispute Resolution Plan (EDR)

In any organization, disputes will arise from time to time. Although we hope your employment will be free of any disputes, should a dispute arise, we believe that it may be brought before a meditator and/or arbitrator in an orderly and cost-effective manner that will benefit both parties. 1. Mediation. To resolve disputes, you and College Works agree to submit all disputes, claims, or controversies arising out of your employment to mediation in Orange County, CA. The mediation may be telephonically or in any other manner reasonably requested by you or College Works. Both you and College Works must agree to the mediator selected, if an agreement cannot be reached, then you and College Works are to proceed to arbitration, pursuant to the terms of this EDR. 2. Arbitration. Should the dispute not be resolved in mediation, then you and College Works agree to submit the dispute to final and binding arbitration in accordance with the rules of the American Arbitration Association (hereinafter AAA) and judgment on the award rendered by the arbitrator may be entered in any court of competent jurisdiction. The arbitrators will be entitled to award all types of relief that would otherwise be available to the parties in a court proceeding under State or Federal law. 2.1 You begin the arbitration process by delivering a written request for arbitration to the company within the time limits which would apply to the filing of a civil complaint in court. A late request will be void. Arbitration must be conducted by the American Arbitration Association (AAA), under its construction arbitration rules. If you and College Works cannot agree to an arbitrator they from an odd-numbered list of experienced employment law arbitrators provided by AAA, each party shall strike one arbitrator from the list alternatively until only one arbitrator remains. 2.2 You and College Works agree that arbitration will take place in Orange County, California.

2.3 The costs of arbitration will be borne equally by the parties. However, if State or Federal law expressly requires that College Works, as the employer, bear the entire cost of arbitration or other costs unique to arbitration for the particular controversy or claim which is the subject of the arbitration proceeding, College Works will then pay the entire cost of arbitration and all such other unique costs, if applicable. You and College Works are each responsible for your own attorneys fees. 2.4 Notwithstanding anything to the contrary, neither You nor College Works will be required to submit to arbitration any disputes that may not lawfully be the subject of a mandatory arbitration provision or any disputes in an amount subject to the jurisdiction of the state court with the lowest monetary jurisdictional limit under State law (e.g., Small Claims Court) which are actually filed in such court. 2.5 Additionally, you agree that all disputes subject to arbitration must be arbitrated as individual claims. You specifically agree not to arbitrate any dispute on a class basis or as a collective action or representative action, and the arbitrator shall have no authority or jurisdiction to enter an award or otherwise provide relief on a class, collective or representative basis. You and College Works specifically retain a right to appeal in a court of competent jurisdiction any determination or award of an arbitrator made in contravention of this section, including without limitation, a determination (i) that a claim may proceed as a class, collective, or representative action; or (ii) that awards relief on a class, collective, or representative basis. In such appeal, the standard of review to be applied to the arbitrators decision shall be the same as that applied by an appellate court reviewing a decision of a trial court sitting without a jury. 3. You acknowledge that you have had the opportunity to consult with your legal counsel regarding the consequences of this Agreement prior to signing it. 4. This Agreement contains the entire agreement and understanding concerning the subject matter between the parties with respect to any of the subject matter hereof, and supersedes and replaces all prior and contemporaneous negotiations, proposed agreements or agreements, whether written or oral. If any of the provisions of this Agreement are found null, void or inoperative, for any reason, the remaining provision will remain in full force and effect to the fullest extent permitted by law. 5. By signing this EDR you will be agreeing that mediation and then arbitration are the sole and exclusive means of resolving any such disputes and agree not to bring any action against the company for any employment-related claim in any court, federal or state. Moreover, you understand that by signing this EDR, you give up your right to a civil trial.

_____________________________ Employee Name (please print)

_____________________________ Employee Signature

_____________________ Date

GENERAL RULES AND POLICIES

The following rules and policies are set forth by College Works Painting in an effort to clarify both the position of the company and the expectations of its employees. Employment with College Works Painting is a seasonal one. A season is defined as summer time, when the Branch Operator is out of school; generally from May to September. Employment is not continuous, nor permanent beyond this seasonal period. Employment is based on an as available basis. Employment with College Works Painting is based on a 90-day trial period. During this time if the employee does not meet company standards (as laid out in the Intern Agreement) College Works Painting has the right to terminate employment without notice or cause. College Works Painting has the option to instate mandatory drug testing in the event of a work related injury. It is the policy of College Works Painting to prohibit harassment (including sexual harassment) of one employee by another employee or supervisor on any basis, including but not limited to veteran status, race, color, religion, sex, marital status, national origin, physical or mental disability or age. Employees who violate this policy are subject to discipline including possible termination. Any employee who feels that (s)he is a victim of harassment should immediately report the incident to the Director of Human Resources at 888-450-9675. X EMPLOYEE PRINT NAME X (SIGNATURE) I UNDERSTAND AND VOLUNTARILY AGREE TO ALL OF THE TERMS OF EMPLOYMENT DESCRIBED ABOVE.

DATE

STANDARDS OF ETHICS
Honesty and trust are the most important aspects of any successful employment relationship. COLLEGE WORKS PAINTING is committed to maintaining a company work ethic built upon honesty and trust and will not knowingly condone any conduct, behavior, or activity that is dishonest or unethical. Any employee who knowingly or intentionally breaches this standard by engaging in conduct or activity including, but not limited to, submitting false statements (written or verbal), the material omission of information, or the misrepresentation of information or fact(s), shall be considered to have willfully disregarded COLLEGE WORKS PAINTING standard of ethics and will be subject to disciplinary action up to and including termination. Moreover, if you are aware of a situation where someone intentionally makes or made false statements, or has engaged in dishonest behavior or activity, and fail to bring it to the attention of management, you will be subject to similar disciplinary action.

EQUAL EMPLOYMENT OPPORTUNITY

Our company is committed to the full utilization of all human resources and to a policy of Equal Employment Opportunity. We make employment and advancement decisions based on each individuals performance, qualifications and abilities. It is the policy of COLLEGE WORKS PAINTING to conduct our relations all employees and applicants for employment without regard to race, color, religion, sex, sexual orientation, pregnancy, age, disability, national origin, marital status, ancestry, medical condition, veterans status or any other characteristics protected by federal or state law. This policy applies to all employment practices, including but not limited to recruitment, hiring, company benefits, compensation decisions, discipline, promotions, demotions, terminations and training so that they will be administered without regard to race, color, religion, sex or sexual orientation, pregnancy, age, disability, national origin, marital status, ancestry, medical condition, veterans status, or any other classification protected by law. We expect all employees to show respect and sensitivity to all other employees, and to demonstrate a commitment to the Companys equal opportunity objectives.

NON-HARASSMENT POLICY (including SEXUAL HARASSMENT)

College Works Painting (the Company) is committed to providing a workplace that is free from all forms of discrimination and conduct that can be considered harassing, coercive or disruptive, including sexual harassment. The Company does not tolerate harassment of any of our employees, customers, independent contractors, vendors or suppliers. Unlawful harassment in employment, including sexual, racial and ethnic harassment, is forbidden by law and is strictly prohibited by the Company. The Company prohibits harassment on any basis including, but not limited to, race, color, religion, sex, marital status, national origin or ancestry, sexual orientation, physical or mental disability, age, medical condition (including pregnancy, childbirth and related medical conditions), genetic characteristics, citizenship, veteran status, physical or mental disability, age, sexual orientation, or any other

consideration based on applicable law. Employees who violate this policy are subject to discipline, including possible termination. The purpose of this policy is not to regulate our employees personal morality. Rather, it is to assure that, in the workplace, no employee harasses another. While it is not easy to define harassment, it certainly includes slurs, epithets, threats, derogatory comments, unwelcome jokes and teasing. Harassment includes, but is not limited to: Visual conduct, including displaying of derogatory objects or pictures, cartoons or posters; Verbal conduct, including making or using derogatory comments, epithets, slurs and jokes. Sexual harassment is defined by the regulations of the Fair Employment and Housing Commission as unwanted sexual advances, or visual, verbal or physical conduct of a sexual nature. Sexual harassment includes gender harassment and harassment on the basis of pregnancy, childbirth, or related medical conditions, and also includes sexual harassment of an employee of the same gender as the harasser. This includes, but is not limited to, the following types of offensive behavior: unwanted sexual advances; offering employment benefits in exchange for sexual favors; making or threatening reprisals after a negative response to sexual advances; visual conduct, including leering, making sexual gestures, displaying of sexually suggestive objects or pictures, cartoons or posters; verbal conduct, including making or using derogatory comments, epithets, slurs and jokes; verbal sexual advances or propositions; verbal abuse of a sexual nature, graphic verbal commentaries about an individuals body, sexually degrading words used to describe an individual, suggestive or obscene letters, notes or invitations; Physical conduct, including touching, assault, impeding or blocking movements. Examples of sexual harassment include (a) an employee being fired or denied a job or an employment benefit because the employee refused to grant sexual favors or because he or she complained about the harassment; (b) an employee reasonably quitting his or her job to escape harassment; or (c) an employee being exposed to a hostile work environment. Any employee who feels that (s) he is a victim of harassment should immediately report such actions in accordance with the following procedure. All complaints will be promptly and thoroughly investigated. COMPLAINT PROCEDURE

1. Any employee who believes that (s) he is a victim of harassment, including sexual harassment, should report the act
immediately to the Director of Human Resources at 888-450-9675 or to your supervisor. If you prefer not to discuss the matter with your supervisor or the Human Resources Director, you may report it directly to an officer or owner.

2. The company will investigate every reported incident immediately. Any employee, supervisor or agent of the
company who has been found to have harassed or sexually harassed another employee may be subject to appropriate disciplinary action, up to and including discharge.

3. The company will conduct all investigations in as discreet a manner as possible. The company recognizes that
every investigation requires a determination based on all the facts in the matter and all persons with information on the matter will be interviewed. We also recognize the serious impact a false accusation can have. We trust that all employees will continue to act responsibly. The reporting employee and any employee participating in any investigation under this policy have the Companys assurance that no punishment or reprisals will be taken as a result of a harassment complaint or inquiry. The Company will take all reasonable steps to prevent harassment from occurring and will take immediate and appropriate action when the Company knows that unlawful harassment has occurred. The Companys determination and related Company action will be communicated to the employee making the complaint, to the alleged harasser and, as appropriate, to all others directly concerned. Prompt and effective remedial action will also be taken by the Company against the harasser, and such action will be communicated to the employee making the complaint. Steps will be taken to prevent further harassment. My signature below confirms that I have read and understand the Companys Harassment Policy, and I agree to abide by this policy.

Name (Printed)

Signature

Date

COLLEGEWORKS PAINTING
EMPLOYEE ACKNOWLEDGEMENT FORM CODE OF SAFE PRACTICES
I (PRINTED NAME), hereby acknowledge that I have received, read, and understand the "Code of Safe Practices" for COLLEGE WORKS PAINTING.

I agree to conform to all practices, safety rules, and regulations relating to safe work performance. I understand that my failure to follow these safety procedures will result in disciplinary action up to and including discharge. I further understand that: a) It is my responsibility to report all unsafe conditions or violations of the Code of Safe Practices to my supervisor or other management personnel in order to minimize the potential of injury to my fellow workers. b) I am encouraged to inform my immediate superior of any hazards on the job without fear or reprisal, and that should my assistance create any such action or related intimidation, that I am encouraged to contact the Safety Officer or management by phone or mail. c) I understand that it is a criminal act to dispose of any paint, paint waste water, solvents, or any other job site waste in neighborhood streets, gutters, or storm drains and will dispose of these items in accordance with Company written Hazardous Materials/Waste Management policies as according to all applicable State and Federal Laws. I also understand that if I do not abide by these rules, I could be dismissed from my job.

(Signature of Employee)

Date

(Signature of Supervisor)

Date

(Printed Name of Supervisor)

Training for Safety

Top 10 Items Urgent: Train your painter on these items NOW
#1 Fall protection needs to be constantly taught and understood by each and every painter. - OSHA in some States is now going around to job sites and asking painters what our fall protection policy is and issuing citations for those managers whose crews can not answer the question. #2 If a ladder is falling DO NOT CATCH IT damaged property can be repaired; a strained back is much more difficult to deal with #3 Always use a three point ladder stance 2 hands and 1 foot or 2 feet and 1 hand should be on the ladder at all times. #4 Use the Belt Buckle rule Always keep your belt buckle inside of the ladder. If you have to reach out so far that your belt buckle goes outside the ladder, stop and move the ladder. #5 The angle of the ladder should be 4:1 a ladder on a 12 ft. roof line should be angled 4 ft from the house. #6 Chemical spills should be treated immediately: READ THE LABEL for poison control instructions so that the chemical can be properly removed/rinsed off. And, always take the chemical instructions to the treatment center so that it can be properly treated. #7 Wear safety glasses make sure that they are provided when needed. Safety glasses must be worn for scraping, sanding, mixing, overhead work, and during windy conditions. #8 Treat insect bites/stings immediately an infection or reaction can happen at any time after the bit/sting. #9 First aid kits must be available at each job site #10 Call for help first in an emergency (911) then call Erica Almanzar at the office. If it is not an emergency, call Erica Almanzar at the office first she will walk you through the proper steps to get the injured person properly cared for. She even has a listing of clinics in your area. Name: __________________________ (Print name) Date: ___________________________

Name: __________________________ (Print name) Date: ___________________________

SAFETY REVIEW TEST

1. Where should first aid kits be available?

2. What Stance should be used when working on a ladder?

3. What is the acceptable time frame to treat a chemical spill?

4. In the event of a work injury that is an emergency, what is the first thing you do? If it is an injury not considered an EMERGENCY who would you call?

5. What do you do if a ladder is falling?

6. When should safety glasses be worn? Give 2 examples.

7. What is the correct angle of a ladder?

8. How often should fall protection be taught?

9. How quickly should you respond to an insect bite or sting?

10. What is the belt buckle rule?

__________________________________ Signature

Form W-4 (2011)

Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes. Exemption from withholding. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2011 expires February 16, 2012. See Pub. 505, Tax Withholding and Estimated Tax. Note. If another person can claim you as a dependent on his or her tax return, you cannot claim exemption from withholding if your income exceeds $950 and includes more than $300 of unearned income (for example, interest and dividends). Basic instructions. If you are not exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding allowances based on itemized deductions, certain credits, adjustments to income, or two-earners/multiple jobs situations.

Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages. Head of household. Generally, you may claim head of household filing status on your tax return only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See Pub. 501, Exemptions, Standard Deduction, and Filing Information, for information. Tax credits. You can take projected tax credits into account in figuring your allowable number of withholding allowances. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below. See Pub. 919, How Do I Adjust My Tax Withholding, for information on converting your other credits into withholding allowances. Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using

Form 1040-ES, Estimated Tax for Individuals. Otherwise, you may owe additional tax. If you have pension or annuity income, see Pub. 919 to find out if you should adjust your withholding on Form W-4 or W-4P. Two earners or multiple jobs. If you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. See Pub. 919 for details. Nonresident alien. If you are a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form. Check your withholding. After your Form W-4 takes effect, use Pub. 919 to see how the amount you are having withheld compares to your projected total tax for 2011. See Pub. 919, especially if your earnings exceed $130,000 (Single) or $180,000 (Married).

Personal Allowances Worksheet (Keep for your records.)

A B C D E F G Enter 1 for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . . A You are single and have only one job; or Enter 1 if: B You are married, have only one job, and your spouse does not work; or . . . Your wages from a second job or your spouses 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 more than one job. (Entering -0- may help you avoid having too little tax withheld.) . . . . . . . . . . . . . . C Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . . D Enter 1 if you will file as head of household on your tax return (see conditions under Head of household above) . . E Enter 1 if you have at least $1,900 of child or dependent care expenses for which you plan to claim a credit . . . F (Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.) Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information. If your total income will be less than $61,000 ($90,000 if married), enter 2 for each eligible child; then less 1 if you have three or more eligible children. If your total income will be between $61,000 and $84,000 ($90,000 and $119,000 if married), enter 1 for each eligible child plus 1 additional if you have six or more eligible children . . . . . . . . . . . . . . . . . . G Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.) H If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions For accuracy, and Adjustments Worksheet on page 2. complete all If you have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed worksheets $40,000 ($10,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld. that apply. 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.
Form 1

Department of the Treasury Internal Revenue Service

W-4

Employee's Withholding Allowance Certificate

Whether you are entitled to claim a certain number of allowances or exemption from withholding is

OMB No. 1545-0074

subject 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. Last name 2 Your social security number

2011

Home address (number and street or rural route) City or town, state, and ZIP code

Single

Married

Married, but withhold at higher Single rate.

Note. If married, but legally separated, or spouse is a nonresident alien, check the Single box. 4 If your last name differs from that shown on your social security card, check here. You must call 1-800-772-1213 for a replacement card.

5 6 7

Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 5 6 $ Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . I claim exemption from withholding for 2011, and I certify that I meet both of the following conditions for exemption. Last year I had a right to a refund of all federal income tax withheld because I had no tax liability and This year I expect a refund of all federal income tax withheld because I expect to have no tax liability. If you meet both conditions, write Exempt here . . . . . . . . . . . . . . . 7

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.

Employees signature (This form is not valid unless you sign it.)
8

Date
9 Office code (optional) 10 Employer identification number (EIN) Form W-4 (2011)

Employers 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.

Cat. No. 10220Q

LISTS OF ACCEPTABLE DOCUMENTS

All documents must be unexpired LIST A Documents that Establish Both Identity and Employment Authorization OR 1. U.S. Passport or U.S. Passport Card LIST B Documents that Establish Identity AND 1. Social Security Account Number card other than one that specifies on the face that the issuance of the card does not authorize employment in the United States LIST C Documents that Establish Employment Authorization

2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551) 3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machinereadable immigrant visa

1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address 3. School ID card with a photograph 4. Voter's registration card 5. U.S. Military card or draft record 6. Military dependent's ID card 7. U.S. Coast Guard Merchant Mariner Card 8. Native American tribal document 9. Driver's license issued by a Canadian government authority For persons under age 18 who are unable to present a document listed above: 10. School record or report card 11. Clinic, doctor, or hospital record 12. Day-care or nursery school record

2. Certification of Birth Abroad issued by the Department of State (Form FS-545)

4. Employment Authorization Document that contains a photograph (Form I-766)

3. Certification of Report of Birth issued by the Department of State (Form DS-1350)

5. In the case of a nonimmigrant alien authorized to work for a specific employer incident to status, a foreign passport with Form I-94 or Form I-94A bearing the same name as the passport and containing an endorsement of the alien's nonimmigrant status, as long as the period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form

4. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal

5. Native American tribal document

6. U.S. Citizen ID Card (Form I-197)

6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

7. Identification Card for Use of Resident Citizen in the United States (Form I-179) 8. Employment authorization document issued by the Department of Homeland Security

Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274)
Form I-9 (Rev. 08/07/09) Y Page 5

OMB No. 1615-0047; Expires 08/31/12 Department of Homeland Security U.S. Citizenship and Immigration Services

Form I-9, Employment Eligibility Verification

Read instructions carefully before completing this form. The instructions must be available during completion of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documents have a future expiration date may also constitute illegal discrimination. Section 1. Employee Information and Verification (To be completed and signed by employee at the time employment begins.)
Print Name: Last Address (Street Name and Number) City State First Middle Initial Maiden Name Apt. # Zip Code Date of Birth (month/day/year) Social Security #

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

I attest, under penalty of perjury, that I am (check one of the following): A citizen of the United States A noncitizen national of the United States (see instructions) A lawful permanent resident (Alien #) An alien authorized to work (Alien # or Admission #) until (expiration date, if applicable - month/day/year)

Employee's Signature

Date (month/day/year)

Preparer and/or Translator Certification (To be completed and signed if Section 1 is prepared by a person other than the employee.) I attest, under
penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct. Preparer's/Translator's Signature Print Name

Address (Street Name and Number, City, State, Zip Code)

Date (month/day/year)

Section 2. Employer Review and Verification (To be completed and signed by employer. Examine one document from List A OR examine one document from List B and one from List C, as listed on the reverse of this form, and record the title, number, and expiration date, if any, of the document(s).) List A OR List B AND List C
Document title: Issuing authority: Document #: Expiration Date (if any): Document #: Expiration Date (if any):

CERTIFICATION: I attest, under penalty of perjury, that I have examined the document(s) presented by the above-named employee, that the above-listed document(s) appear to be genuine and to relate to the employee named, that the employee began employment on (month/day/year) and that to the best of my knowledge the employee is authorized to work in the United States. (State employment agencies may omit the date the employee began employment.)
Signature of Employer or Authorized Representative Print Name Title Date (month/day/year)

Business or Organization Name and Address (Street Name and Number, City, State, Zip Code)

Section 3. Updating and Reverification (To be completed and signed by employer.)

A. New Name (if applicable) B. Date of Rehire (month/day/year) (if applicable)

C. If employee's previous grant of work authorization has expired, provide the information below for the document that establishes current employment authorization. Document Title: Document #: Expiration Date (if any): l attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) l have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative Date (month/day/year) Form I-9 (Rev. 08/07/09) Y Page 4