APPLICATION FOR EMPLOYMENT REF 042 Rev J (12/14) Page 1 of 4 It is the policy of this company to provide equal employment opportunities to all qualified persons without regard to race, creed, color, religious belief, gender, sexual preference, age, national origin, physical or mental handicap or veteran status and to satisfy the requirements of The Americans with Disabilities Act of 1990 (as amended) as well as state laws governing the employment of individuals with disabilities. Note: Please type or print your answers. If you print, please do so in blue or black ink and write neatly. An illegible application may preclude you from consideration. Position Applying For: ______________________________________________________________________ Application Date: __________________________________________________________________________ Are you at least 18 years of age? Yes No Personal Information ________________________________________________________________________________________ First Name Middle Initial Last Name Current Address: __________________________________________________________________________________________________________ Street and Apt. # City State Zip Code Permanent Address (if different from above): __________________________________________________________________________________________________________ Street and Apt. # City State Zip Code Telephone: __________________ Cell Phone: ________________ E-Mail: _________________________ Please provide an email address that the company may utilize to provide notifications. Person to be notified in case of an accident or emergency: Name Relationship Telephone / Cell Phone Number For positions requiring driving or operating a vehicle for business use: Do you have a valid Driver’s License? Yes No Driver’s License #: ________________State:_______ Have you ever served in the U.S. Military? Yes No If yes, please provide the following information: Branch of Service: _______________________ Rank at Time of Separation: ________________ Service Dates: __________________________ Special Honors: __________________________
Transcript
APPLICATION FOR EMPLOYMENT
REF 042 Rev J (12/14) Page 1 of 4
It is the policy of this company to provide equal employment opportunities to all qualified persons without regard to race, creed, color, religious belief, gender, sexual preference, age, national origin, physical or mental handicap or veteran status and to satisfy the requirements of The Americans with Disabilities Act of 1990 (as amended) as well as state laws governing the employment of individuals with disabilities.
Note: Please type or print your answers. If you print, please do so in blue or black ink and write neatly. An illegible application may preclude you from consideration.
Position Applying For: ______________________________________________________________________ Application Date: __________________________________________________________________________ Are you at least 18 years of age? Yes No Personal Information ________________________________________________________________________________________ First Name Middle Initial Last Name Current Address: __________________________________________________________________________________________________________ Street and Apt. # City State Zip Code Permanent Address (if different from above): __________________________________________________________________________________________________________ Street and Apt. # City State Zip Code Telephone: __________________ Cell Phone: ________________ E-Mail: _________________________
Please provide an email address that the company may utilize to provide notifications.
Person to be notified in case of an accident or emergency: Name Relationship Telephone / Cell Phone Number For positions requiring driving or operating a vehicle for business use:
Do you have a valid Driver’s License? Yes No Driver’s License #: ________________State:_______ Have you ever served in the U.S. Military? Yes No If yes, please provide the following information:
Branch of Service: _______________________ Rank at Time of Separation: ________________ Service Dates: __________________________ Special Honors: __________________________
APPLICATION FOR EMPLOYMENT
REF 042 Rev J (12/14) Page 2 of 4
First Name: Middle Initial: Last Name: Employment History
Has Resume Been Submitted: Yes No Present or Most Recent Employer: (if yes, skip to page 3) Employer: _________________________________ Address: ______________________________________________ Position: __________________________________ Salary: ________________________________________________ Duties: Dates of Employment: From _________________________ To ______________ May we contact? Yes No Supervisor: _________________________________ Title: _________________________________________________ Reasons for Leaving: Prior Employer: Employer: _________________________________ Address: ______________________________________________ Position: __________________________________ Salary: ________________________________________________ Duties: Dates of Employment: From _________________________ To ______________ May we contact? Yes No
Supervisor: _________________________________ Title: _________________________________________________ Reasons for Leaving: Prior Employer: Employer: _________________________________ Address: ______________________________________________ Position: __________________________________ Salary: ________________________________________________ Duties: Dates of Employment: From _________________________ To ______________ May we contact? Yes No Supervisor: _________________________________ Title: _________________________________________________ Reasons for Leaving:
APPLICATION FOR EMPLOYMENT
REF 042 Rev J (12/14) Page 3 of 4
First Name: Middle Initial: Last Name: Education High School: _____________________________________________________________________________ Address: ________________________________________________________________________________ Technical or Vocational School: ________________________________ Specialty:_____________________ Did you graduate? Yes No Attended From ______________ To _________________________ If you did not graduate, did you receive your GED? Yes No Special honors or awards: ___________________________________________________________________ College or University: ______________________________________________________________________ Address: ________________________________________________________________________________ Did you graduate? Yes No Attended From ______________ To __________________________ Degree: _______________________________ Major: ____________________________________________ Special honors or awards: __________________________________________________________________ Position Information Position Applying For: ______________________________________________________________________ How did you hear about this job? _____________________________________________________________ What hours are you willing to work? ___________________________________________________________ Would you be able to work weekends? Yes No Are you willing to travel for the job? Yes No When would you be able to start? _____________________________________________________________ Desired Salary: _____________________________ Per Diem: ________________________________
APPLICATION FOR EMPLOYMENT
REF 042 Rev J (12/14) Page 4 of 4
First Name: Middle Initial: Last Name: Skills
Please describe any skills you have in the following areas:
Computer: ________________________________________________________________________________________ Languages Spoken (other than English): ________________________________________________________________ Additional Skills: ____________________________________________________________________________________ Certifications: ______________________________________________________________________________________
I hereby certify that my answers and assertions set forth in this application are true and complete to the best of my knowledge. If I am employed, I understand that any false statements on this application shall be considered sufficient cause for my dismissal. I understand that I may be required to submit to a background screening process during the next step of pre-employment testing and evaluation and that I will be given the opportunity to discuss any concerns that I may have with regards to this screening process during a personal interview (conducted either in person or via telephone). If I choose to continue in the screening process, I understand that I may be required to sign a release authorizing a background screening company designated by the Employer noted on this application and or its clients to whom I may be assigned to investigate my personal information for the sole purpose of determining employment eligibility. The personal information investigated may include but is not limited to, employment history, educational verifications, drug testing, credit reports (subject to all Fair Credit Reporting Act requirements) motor vehicle screens and criminal records investigation. I understand that in order to be made an offer of employment, any and all required screens that I submit to must meet the requirements of the Employer and or their clients to whom I would be assigned. I release and forever discharge the Employer noted on this application, its clients, the background screening company, laboratories and the agents and employees of all noted from any lawsuits, proceedings, claims or causes of action arising from the test or tests and from any action or inaction of the Employer and or its clients based on the results of the testing. I understand that should I become employed in Massachusetts and should my assignment/employment end that MA Employment and Training Law requires that I contact my Employer for possible reassignment prior to filing for unemployment insurance benefits. Failure to do so may result in a denial of those benefits. Furthermore I understand that if I am hired, employment with the Employer noted on this application is "at will," which means that either the Employer or I can terminate my employment for any reason not prohibited by state or federal law. Signature: _________________________________________________ Date: ________________________ Print Name: ________________________________________________
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REF 072 Rev B (11/15) Page 1 of 1
Madison Resource Funding is a proud participant of the Federal WOTC (Work Opportunity Tax Credit) program. The WOTC program is a Federal tax credit available to employers in an effort to incentivize workplace diversity and facilitate access to good jobs for American workers. Each year, employers claim over $1 billion in tax credits under the WOTC program. The success and growth of this program has been beneficial to increasing America’s economic growth and productivity.
This program requires that employers have all potential new hires complete a screening process. We have partnered with Equifax, utilizing a convenient phone screening method that is secure and efficient.
• Please complete the screening by calling the below number. You will then be prompted for the Employer Code and Location Code. After entering you will then answer a series of automated questions to determine eligibility for the tax credits.
• Once you have completed the process, you will be given a confirmation code. Please record that number below where indicated
WOTC Screening Toll Free Number 1-800-552-5469 Client Name Madison Resource Funding
Employer Code 72820
Location Code 72820
Confirmation Number
We thank you for your participation!
DIRECT DEPOSIT FORM
CALIFORNIA
MAF 307-A CA (01/17) Page 1 of 1
NESC Staffing Corp. offers two FAST, EASY and SAFE ways to get paid in California: • Option 1 - Direct Deposit to a Personal Bank Account: If you have a personal checking or saving
account, your pay can be delivered to that account via direct deposit every payday. • Option 2 - Money Network® Service: If you don’t have a personal bank account, your pay will be loaded
directly into your Money Network Account every payday. This easy-to-use payroll solution enables you to access your funds by using Money Network™ Checks or an optional Money Network® Paycard. Write a Check to yourself and cash it for free to get up to 100% of the funds in your account, make free cash withdrawals at In-Network AllPoint ATMs and Bank of America ATMs nationwide (at least one free withdrawal per pay period), pay bills, make purchases and more.
Take Charge of your Pay. Whether you choose Direct Deposit or Money Network, you get more control over your pay. Among key benefits you’ll be able to count on:
• Save time: your pay is automatically deposited into your personal bank account or your Money Network account every payday. Rain, snow or shine, you’ll be able to access your pay immediately on payday, instead of waiting to pick up your check or standing in line to cash it.
• Save money: every penny of your hard-earned money counts. These payroll options give you instant and convenient ways to access to your pay for free 24/7, so you can say goodbye to check cashing and/or money order fees.
• Keep it safe: your pay is automatically placed into your account, giving you peace of mind -- you don’t have to worry about lost checks or stolen cash.
• Eco-friendly: these options require less paper, which helps minimize environmental waste and pollutants. After careful evaluation, we believe Direct Deposit and Money Network are the best available payroll solutions to help us meet our goal of delivering your pay in the quickest and most secure way possible. Due to California state law and as an employee in California I understand I have only two options to get paid. If I choose Direct Deposit, I will also include the necessary paperwork so funds can be deposited into my bank account each pay day otherwise the Money Network option is your choice. Please speak with your NESC Staffing recruiter for more information on this option. My signature below indicates that I have read, understand and authorize the mode of payment below. Direct Deposit: Money Network: Employee:
(Signature)
Print Name: Date:
DIRECT DEPOSIT FORM
MAF 307 Rev F (12/14) Page 1 of 1
Do You Want Direct Deposit? Yes No (If yes, please attach a voided check to this form and forward to your branch representative for processing). Account #1:
Employee Bank Name:
Bank Routing (ABA) #: Account No.:
Amount: Checking Savings Account #2 (optional):
Employee Bank Name:
Bank Routing (ABA) #: Account No.:
Amount: Checking Savings
Note: This Process May Take Up To 2-3 Weeks But Will Not Delay Or Hold Back Your Paycheck. I hereby authorize (the “Company”) to deposit any amounts owed me, as instructed by my employer, by initiating credit entries to my account at the financial institution (hereinafter “Bank”) indicated on this form. Further, I authorize Bank to accept and to credit any credit entries indicated by the Company to my account. In the event that the Company deposits funds erroneously into my account, I authorize the Company to debit my account for an amount not to exceed the original amount of the erroneous credit. This authorization will be in effect until the Company receives a written termination notice from myself and has a reasonable opportunity to act on it.
Signature Date
Print Name
Please submit completed form to your branch representative via fax or mail. The safety and security of your financial information is of primary importance to us. Due to the sensitive nature of the information; submitting
electronically is not advised without the use of a secure web portal, and if done so, will be at your own risk.
Office Use Only
Submitted By: Company: Date Submitted:
Office Location/Branch: Effective Date:
Direct Deposit Disclaimer: If you are eligible for and choose to enroll in Direct Deposit we recommend that you verify with your bank or financial institution when your funds would be posted to your account and made available to you. Each bank and financial institution has its own process for funds availability.
Pay stubs are now electronically available through Employee Self Service via the Internet and therefore accessible at home, the library, or wherever you may choose to access your account. In addition to making this information more convenient for employees, it also represents a significant step forward in the Company’s effort to "go green" and to conserve resources. Direct deposit employees will no longer receive a paper pay stub. Instead, each week, on the evening before your payday, (a day later on a holiday week) your pay stub information will be uploaded to the secure website where it can be easily accessed from your PC. You will be able to view and print both current and loaded historical pay stubs. As always, if you need any historical information, not accessible on the website (mortgage verification, SSA, etc.) please contact your Payroll Administrator and they can quickly provide the required information to you or the requesting agency.
Please log on to https://nescpaystubs.madisonrf.com
● Your User Name is your LAST NAME (first letter capitalized) and the last 4 digits of your social security
number. Example: Smith1234
● Your password is the last 4 digits of your social security number.
● Click on “Employee” on the left.
● Click on “Direct Deposit” The most current pay stub will be presented first. You can see pervious stubs by clicking the red “Previous” button at the top left of the screen. To move to the more recent pay stubs click “Next” at the top right of the screen. Click on “Change Password” at the far left to change your password at any time. If you have any technical issues relative to the website, or any questions relative to your check, hours, rate, bank information, etc., please contact your local branch representative.
Paystubs Paystubs are typically uploaded to our secure website and should be available online the next business day after your payday. To access, follow the instruction above to log into your account then click on “Paystubs” located at the top of the page; then one of the choices;
“Home” will give you a list of your last 5 paystubs and their date;
“My Account” gives you information regarding your account and this is where you can change your password and/or email address.
“Employee Paystub” gives you a listing of all paystubs, year to date,
“YTD” will give you an overall breakdown of Current YTD
HRF 216 Rev A (12/15)
To: All Employees
RE: New Health Insurance Marketplace Coverage Options
In 2014, the health care reform law created a new type of online marketplace for purchasing health insurance coverage. This marketplace is referred to as a Health Insurance Marketplace or an Exchange. You are not required to purchase insurance coverage through the Marketplace. This letter is being sent to all employees of NESC Staffing, Corp. regardless of your current status of being eligible for health insurance through the agency.
NESC Staffing, Corp. is providing the enclosed notice to help you understand your health insurance coverage options.
If you purchase coverage through a Marketplace, you may be eligible for a federal subsidy that lowers your monthly premiums or reduces your cost sharing.
If you have any questions, additional information regarding health care reform law and the Marketplaces is available at www.healthcare.gov.
Plan Year: _________ To decline coverage through Employer sponsored plan, please sign and return this form to your NESC Staffing, Corp. branch.
Employee Name: Last First MI
Date of Birth: ______________ I waive my and/or my dependents’ (if any) eligibility to enroll in my employer’s group plan at this time. I understand that I and/or my dependents may enroll under this plan in the future under the terms defined in the eligibility section of the insurance carriers subscriber certificate or benefit description.
Employee Signature Date
EMPLOYEE PATENT-LICENSE-COPYRIGHT AGREEMENT
REF 052 Rev G (12/14) Page 1 of 1
In consideration of my employment with NESC Staffing, Corp. (hereinafter, the Company), I agree that as a condition of my employment as a contractor, I hereby covenant and agree that: 1. I agree that I will promptly disclose to Company, and its Client, all discoveries, processes, software, formulae,
data, know-how and techniques, whether or not patentable or protectable by copyright, made or conceived, first reduced to practice, or learned by me, either alone or jointly with others, during the period of my engagement by Company as contractor for Client that (i) relate to or are useful in the business of Company and/or its clients, (ii) are conceived, made or worked on at the expense of, or during my normal working hours for Client or using any resources or materials of Client, or (iii) arise out of tasks assigned to me by Client or, (iv) are within the scope of my duties as employee of Company while on the Client project (collectively, “Proprietary Inventions”).
2. All Proprietary Inventions shall be a work for hire and the sole property of Client and its assignees, and Client
Company and its assignees shall be the sole owner of all patents, copyrights, trademarks, and other rights in connection therewith. In consideration of my engagement by Company as an employee/contractor and regardless of any change in the wages paid to me or the nature of my duties, I hereby assign to Client, or its assignees, my entire right, title and interest in and to any and all Proprietary Inventions including all patent, trademark, copyright, and other rights therein.
3. I, at the expense of Client, agree to assist Client and its assignees in every proper way to obtain and enforce
patents, copyrights, trademarks and other intellectual property rights in Proprietary Inventions in the United States and any and all other countries. To that end, I agree to execute all papers and perform all acts necessary to make this Agreement effective as to any particular Proprietary Inventions, application for letters of patent, registration of copyrights or trademarks, and other rights and interests of Client or its assignees, including the giving of testimony without expense to me and without further compensation. My obligations under this paragraph (3) shall continue beyond the termination of this Agreement, my assignment to Client and my duties as employee of Company.
4. I acknowledge that Company and Client have developed or acquired materials and information (whether or not
reduced to writing, patentable or protectable by copyright) relating to their business clients, customers, consultants, licensees or affiliates including but not limited to operating procedures, products, methods, service techniques, engineering and manufacturing data, machines, devices, apparatus, “know-how,” formulae, software, object and source code, processes, plans, designs, including photographic representations, specifications, trade secrets, company data regarding costs, profits, markets and sales, customer lists, plans for present and future research, development and marketing, and other proprietary information not available to the public (collectively “Proprietary Information”)and that such proprietary information may be available to me in the course of my employment. I will not, without the express written authorization from an authorized Company or Client officer, during or after the term of my engagement by Company as employee, disclose any Proprietary Information, or anything relating to it (whether or not learned, obtained or developed solely by me), to any person other than authorized Client personnel. Nor shall I use any such Proprietary Information except in the scope of my employment, for my personal benefit or disclose or use for my benefit any information furnished by a third party to Company in confidence.
5. I further agree that all of the above applies to all Company’s clients to which I am assigned.
Employee: Witness
(Signature) (Signature)
Print Name: Print Name:
Date: Date:
ALCOHOL AND DRUG FREE WORKPLACE POLICY
HRF 181 Rev D (12/14) Page 1 of 1
Purpose: To establish and explain the Company’s policy with regards to an alcohol and drug-free workplace. Scope: This applies to all staff and contractors wherever they are located. Definitions: OTC Over the counter Procedure: Substance abuse has an adverse impact on an employee’s work, personal and family lives, as well as on the ability of our company to fulfill its mission to provide the highest quality services to its clients. It can cause poor performance, decrease productivity, and create safety hazards. Consequently, our company is committed to establishing and maintaining an alcohol and drug-free workplace. Illegal Drugs: The use, distribution, dispensation, sale, offering for sale, possession, purchase, manufacture, or trading of illegal drugs on our company’s premises, client premises, or in any other work-related environment is strictly prohibited. The prohibition of illegal drug activity includes occasions when an employee is representing our company or one of our company’s clients at events and meetings beyond normal work hours. Alcohol: Employees are not permitted to consume alcohol while on the company’s premises, client premises, or while conducting the company’s business. This does not include official day or evening functions at which alcohol may be served, as long as use does not prevent employees from performing their jobs competently or pose any threat to the safety or welfare of the employee or others. Prescription and OTC Drugs: Employees are prohibited from the misuse or abuse of prescription and over-the-counter (“OTC”) drugs. Employees who are using prescribed or OTC drugs for existing medical conditions should notify their Employers Representative if they feel they may require a temporary alteration of job duties or assignment if the drugs (1) may have possible side effects, which may affect job performance, or (2) alter an employee’s physical or mental abilities. Policy Violations: Employees who violate this policy are subject to disciplinary action, up to and including termination.
Policy acknowledgement and signature required under Employee Hourly Contract and Obligations (REF 051)
DRUG TEST AUTHORIZATION
REF 048 Rev E (12/14) Page 1 of 1
Certain clients of NESC Staffing, Corp. (NESC) require that employees assigned to it successfully pass a substance abuse test. As a condition for consideration for assignments with certain clients of NESC, I, , voluntarily authorize any laboratory designated by NESC, or its clients to conduct a test or tests for the purpose of determining the presence of drugs or alcohol in my system. I consent to the release by the laboratory designated by NESC, or its clients of the results of the drug and alcohol test or drug test to both NESC and its clients for the sole purpose of determining employment eligibility. I further agree that if my drug test should be returned to NESC with a Positive result, I may be required to reimburse NESC for the total cost of the drug test. I further agree that should either my Employer or the Client Company where I am assigned have reasonable suspicion that I am on any work premise while under the influence of drugs and or alcohol that I may be required to submit to a Drug and or Alcohol Screening Test while employed and that if the results of the test are positive, my employment will be terminated immediately. I also acknowledge that I may be required to submit to a post-accident substance abuse test if I am injured on the job and that if my drug test should be returned with a Positive result, my employment will be terminated immediately and I may not be eligible for Worker’s Compensation benefits. I also acknowledge that the Client Company where I am assigned may require random drug tests as part of their Company Policy and should that be the case for any Client Company where I am assigned, then I consent in advance to submit to a random drug screen if and when selected and should the drug test be returned with a Positive result, my employment will be terminated immediately. I hereby release and forever discharge NESC, its clients, the laboratory, and the agents and employees of any of them, of and from any and all lawsuits, proceedings, claims or causes of action arising from the test or tests, and from any action or inaction of NESC or its clients based on the results of the testing. I understand the meaning of this release and consent form, and I have had the opportunity to raise any questions about it before signing it. My signature below is completely voluntary, without coercion or duress of any kind, and I am signing this release and consent form solely as a condition for consideration of assignments with NESC’s Clients. Employee: Representative
(Signature) (Signature)
Print Name: Print Name:
Date: Date:
BACKGROUND SCREENING AUTHORIZATION
HRF 184 EMP Rev C (12/14) Initial:
Disclosure Regarding Background Investigation The Fair Credit Reporting Act (FCRA), states that a disclosure should be provided to the consumer before a consumer or investigatory report is obtained by a Consumer Reporting Agency (CRA).
has been named the designated CRA and, and on behalf your prospective or current employer, we will obtain one or more consumer reports or investigative consumer reports (or both) about you for employment purposes. The reports are commonly known as “background check reports” and will be used for the purposes of evaluating you for employment, promotion, reassignment, retention or termination.
, or an approved consumer reporting agency will assist in conducting the background investigation for your prospective or current employer. The background reports may include information about your character, general reputation, personal characteristics, and/or mode of living. To prepare the reports, our investigations may include but are not limited to your education history, current/former work history, professional licenses and credentials, references, address history, social security number validity, right to work, criminal record, lawsuits, driving record, credit history, subject to any limitation imposed by applicable federal and state laws. You may request additional information about your background report by oral, written or electronic means. Trained personnel will be available to explain your file to you, including any coded information. Please contact your branch representative for further information. You have the right to obtain a complete and accurate copy of the completed reported which properly reflects the nature and scope of the investigation performed. A summary of your rights under the Fair Credit Reporting Act (FCRA) is also being provided to you. Please sign below to acknowledge your receipt of this disclosure.
Signature
Date:
Print Name:
This packet consists of 4 pages. Please initial each page in the lower right hand corner indicating that you have received and read the information. (Additional information Regarding Rights
under the Fair Credit Reporting Act can be found under “Resources” on our website)
BACKGROUND SCREENING AUTHORIZATION
HRF 184 EMP Rev C (12/14) Initial:
Background Investigation Application and Authorization Release
Last Name First Name Middle Name
Former, Alias or Maiden Name Email Address Telephone#
Driver’s License Number D.L. State Date of Birth (mm/dd/yyyy) Social Security#
Please list your CURRENT and PAST home addresses for the last 7 years with the most recent first:
Address City State Zip From To
1.
2.
3.
4.
Education Please list highest degree achieved (with graduation date) as well the school attended. Highest Education Completed: GED High School College Masters Other ______________________________
Institution Name City, State Major/Subject Graduation Date
Did you graduate under a different name? Ye s No If ye s , e nte r full name :________________________
Employment History
Most Recent Employer Employer 2 Employer3
Employer Name
Address, City, State
Phone
Supervisor
Start Date (m/d/yyyy)
End Date (m/d/yyyy)
Title
Salary
Reason for Leaving
May We Contact? Yes No Yes No Yes No
BACKGROUND SCREENING AUTHORIZATION
HRF 184 EMP Rev C (12/14) Initial:
Professional References
Reference 1 Reference 2 Reference 3 Full Name Street Address City and State Phone Email Address Relationship Employer
Print Full Name:
Authorization Release for Background Investigation I acknowledge receipt of the Disclosure and I certify that the information I provided on this application is true and accurate to the best of my knowledge. I hereby consent to have a background investigation made relating to statements made on my application, and consent to have such information reported to the designated CRA, my prospective employer or current employer at any time after receipt of this authorization and throughout my employment, if applicable. I also agree to give any further information which may be required in reference to my past record. I also authorize and request every person, firm, credit bureau, company, corporation, governmental agency, court, financial institutions, employer, police department, motor vehicle department, workers compensation agency, licensing agency, schools, colleges, universities, and any other association or institution having control of any documents, records and other information pertaining to me, to furnish to the designated CRA, or its designated agents any such information, background reviews, driving records, employment records, including documents, records, files containing charges or complaints filed against me, formal or informal, pending or closed, or any other pertinent data, and to permit the designated CRA, or its agents to inspect and make copies of such documents, records and other information. I further authorize the designated CRA to furnish interested employer(s) and their authorized agents a report relating to statements I made in this application. Except as otherwise prohibited by law, I hereby release, waive, discharge, exonerate and agree not to sue the designated CRA, it’s agents, representatives, employees, independent contractors, officers, directors, and shareholders from and for any all claims, damages, losses, liabilities, rights expenses, demands, causes of actions of any nature whatsoever arising out of or related to the designated CRA whether such information, documents or records are provided directly to them, its agents by me or obtained independently by the designated CRA, my prospective or current employer, or its agents on my behalf. I also agree that this Disclosure and Authorization in original, faxed, photocopied, or electronic (including electronically signed) form will be valid for any consumer reports or investigative consumer reports that may be requested about me by or on behalf of the designated CRA and my prospective employer or current employer. As evidenced by my signature below on this application, I assert my clear understanding and agreement that any and all results from the Background Investigation initiated based upon this application may be shared with the designated CRA and my prospective or current employer. A summary of your rights under the Federal Credit Reporting Act (FCRA) is attached. Please sign below to acknowledge your receipt of this disclosure.
Signature Date:
BACKGROUND SCREENING AUTHORIZATION
HRF 184 EMP Rev C (12/14) Initial:
Disclaimer: in addition to the foregoing disclosure and authorization form needed to comply with the Federal Credit Reporting Act (FCRA), various states impose additional disclosure or other obligations on employers when they obtain consumer reports or investigative consumer reports on employees or applicants. You should review your state’s laws and regulations in this regard. The following is a summary of possible state requirements that may apply to you California, Maine, Massachusetts, Minnesota, New Jersey & Oklahoma Applicants Only: I have the right to
request a copy of any Report obtained by NESC Staffing, Corp. from the designated CRA by checking the box. (Check only if you wish to receive a copy)
California, Connecticut, Maryland, Oregon and Washington State Applicants Only (AS APPLICABLE): I further understand that NESC Staffing, Corp. will not obtain information about my credit history, credit worthiness, credit standing, or credit capacity unless: (i) the information is required by law; (ii) I am seeking employment with a financial institution (California and Connecticut only – in California the financial institution must be subject to Sections 6801-6809 of the U.S. Code); (iii) I am seeking employment with a financial institution that accepts deposits that are insured by a federal agency, or an affiliate or subsidiary of the financial institution or a credit union share guaranty corporation that is approved by the Maryland Commissioner of Financial Regulation or an entity or an affiliate of the entity that is registered as an investment advisor with the United States Securities and Exchange Commission (Maryland only); (iv) the information is substantially job related, and the bona fide reasons for using the information are disclosed to me in writing,[Complete the question below] (Connecticut, Maryland, Oregon and Washington only);(v) I am seeking employment as a covered police, officer , peace officer or other law enforcement position (California and Oregon only - in Oregon the police or peace officer position must be sought with a federally insured bank or credit union ) , (vi) the COMPANY reasonably believes I have engaged in specific activity that constitutes a violation of law related to my employment (Connecticut only), (vii) I am seeking a position with the state Department of Justice (California only), (viii) I am seeking a position as an exempt managerial employee (California only), or (viii)) I am seeking employment in a position that involves regular access to personal information of others (i.e., bank or credit card account information, social security numbers, dates of birth), other than regular solicitation of credit card applications at a retail establishment, I am seeking employment in a position that requires me to be a named signatory on the employer’s bank or credit card or otherwise authorized to enter into financial contracts on behalf of the employer, I am seeking employment in a position that involves access to confidential or proprietary information of the Company or regular access to $10,000 or more in cash (California only). Bona fide reasons why COMPANY considers credit information substantially job related [Complete if this is the sole basis for obtaining credit information] or in California the COMPANY’S basis for the credit check:
NY Applicants Only: I also acknowledge that I have received the attached copy of Article 23A of New York’s Correction Law. I further understand that I may request a copy of any investigative consumer report by contacting the designated CRA. I further understand that I will be advised if any further checks are requested and provided the name and address of the consumer reporting agency. California Applicants and Residents: If I am applying for employment in California or reside in California, I understand I have the right to visually inspect the files concerning me maintained by an investigative consumer reporting agency during normal business hours and upon reasonable notice. The inspection can be done in person, and, if I appear in person and furnish proper identification; I am entitled to a copy of the file for a fee not to exceed the actual costs of duplication. I am entitled to be accompanied by one person of my choosing, who shall furnish reasonable identification. The inspection can also be done via certified mail if I make a written request, with proper identification, for copies to be sent to a specified addressee. I can also request a summary of the information to be provided by telephone if I make a written request, with proper identification for telephone disclosure, and the toll charge, if any, for the telephone call is prepaid by or directly charged to me. I further understand that the investigative consumer reporting agency shall provide trained personnel to explain to me any of the information furnished to me; I shall receive from the investigative consumer reporting agency a written explanation of any coded information contained in files maintained on me. “Proper identification” as used in this paragraph means information generally deemed sufficient to identify a person, including documents such as a valid driver’s license, social security account number, military identification card and credit cards.
Signature Date
GENERAL SAFETY RULES
SAF 154 Rev B (12/14) Page 1 of 1
NESC Staffing, Corp. has developed these safety rules patterned after the Federal OSHA requirements. Please read and become familiar with these rules, and other safety rules that apply to your job.
1. Report any injuries to your on-site supervisor as well as your employer immediately.
2. Report any observed unsafe condition to your employer/supervisor.
3. Horseplay is prohibited at all times.
4. The drinking of alcoholic beverages is not permitted on the job. Any employee discovered under the influence of alcohol or drugs will not be permitted to work.
5. If you do not have current First Aid Training, do not move or treat an injured person unless there is an immediate peril, such as profuse bleeding or stoppage of breathing.
6. Appropriate clothing and footwear must be worn on the job at all times.
7. Where there exists the hazard of falling objects, an approved hard hat must be worn.
8. You should not perform any task unless you are trained to do so and are aware of the hazards associated with that task.
9. You may be assigned certain personal protective safety equipment. This equipment should be available for use on the job, be maintained in good condition, and worn when required.
10. Learn safe work practices. When in doubt about performing a task safely, contact your supervisor for instruction and training.
11. The riding of a hoist hook, or on other equipment not deigned for such purposes, is prohibited at all times.
12. Never remove or by-pass safety devices.
13. Do not approach operating machinery from the blind side; let the operator see you.
14. Learn where fire extinguishers and first aid kits are located.
15. Maintain a general condition of good housekeeping in all work areas at all times.
16. Be alert to hazards that could affect you and your co-employees.
17. Obey safety signs and tags.
18. Always perform your assigned task in a safe and proper manner; do not take shortcuts. The taking of shortcuts and the ignoring of established safety rules is a leading cause of employee injury.
I certify that I have read and understand and will abide by the above listed safety rules. Failure to do so may be grounds for termination and may disqualify potential worker’s compensation benefit eligibility. Employee __________________________________ Print Name: _____________________________ (Signature) Date: _____________________________
SAFETY VIDEO TEST
SAF 162 Rev E (01/16) Page 1 of 1
Note: This Form Must Be Completed At Your Nearest Branch Office or
Verified By A Designated Representative At Your Job Site.
Please complete the following: True or False 1. You will be drug tested if you have an on-the-job injury. _______ 2. If you fail to comply with both the staffing service and the client’s safety rules, your employment may be
terminated. _______ 3. You are allowed to drive a forklift at work. _______ 4. As an employee in the workplace, you are expected to take risks, even if it is only a clerical job. _______ 5. If you observe hazardous conditions or unsafe work practices, you should keep it to yourself. _______ Multiple Choice 6. Haz-Com Training is: _______
A. Training on the hazards and precautions to use when working with chemicals or hazardous material B. A foreign language class C. A training program for machine operation
7. When lifting a load, you should: _______
A. Jerk your back to add power B. Bend at the waist C. Use your legs and keep your back straight
8. If your supervisor asks you to operate machinery or equipment you have not been trained to use, you
should: _______
A. Go ahead and operate the equipment B. Tell your supervisor that you have not been trained in the use of the equipment C. Figure it out by yourself
9. You should report an accident and/or on-the-job injury: _______
A. On Monday B. As soon as it happens C. At the end of your shift
10. Your employer is: _______
A. The government B. The company where you are working temporarily C. NESC Staffing, Corp.
Employee:
(Signature)
Print Name: Date:
THE HAZARDOUS COMMUNICATION STANDARD
JOBSITE POSTER
SAF 163 Rev B (12/14) Page 1 of 1
*Note: Employees Will Be Trained on the Following Hazard Communication Program by Client at Work Site
THIS COMPANY HAS A WRITTEN HAZARD COMMUNICATION PROGRAM
IN COMPLIANCE WITH OSHA 1926.59 In accordance with the following, these standard items are available to you on request
Copy of the Company Written Communication Program Copy of the OSHA Hazard Communication Standard Copy of the Company’s list of Hazard Chemicals for your workplace Copies of Safety Data Sheets for any covered chemicals to which you are
exposed
To Obtain Any or All of This Information Contact Your Supervisor
The Safety Data Sheet Collection for hazardous chemicals on this jobsite is located at: ___________________________________________________ The Written Hazard Communication Program for this Jobsite is located at: ___________________________________________________________ The Hazardous Chemical List for this jobsite is located at: ___________________________________________________________ Questions regarding chemicals, chemical handling or health and safety should be directed to: __________________________________________
WORKERS COMPENSATION
MEDICAL TREATMENT PROGRAM
SAF 166 Rev G (12/16) Page 1 of 1
1-855-288-9490 When prompted for Employer Name, you will let them know that it is listed under
the “NESC Umbrella”.
The Location Code is based on what branch office you are employed out of: Portsmouth, NH: NESC PORTSMOUTH Woburn, MA: NESC WOBURN Houston, TX: NESC HOUSTON Boca Raton, FL: NESC BOCA RATON Garland, TX: NESC GARLAND Walnut Creek, CA: NESC WALNUT CREEK Scottsdale, AZ: NESC SCOTTSDALE Plymouth Meeting, PA: NESC PLYMOUTH MEETING Hartford, CT: NESC HARTFORD
Then provide your Zip Code so the nurse can locate care in your area.
Worker’s Compensation Insurance Carrier
Old Republic Insurance Company 445 South Moorland Road, Suite 300
Brookfield, WI 53005 (262) 797-3400 • (800) 766-5673
It is our hope that you will never have an injury or health problem as a result of your work. However, if you do, we at NESC Staffing, Corp. will be ready to assist you. It is extremely important that you understand and comply with the procedures that follow should you ever require medical treatment for a work related injury:
EMERGENCY CARE In the event of an emergency, please seek immediate medical care by calling 9-1-1 or going to the nearest hospital or urgent care facility. As soon as you are able, notify your branch office to report the incident.
NON-EMERGENCY CARE1. Report injury to your immediate on-site supervisor 2. Call our Priority Care Hotline (PC365) to speak with a registered nurse. PC365 has nurses available
24/7/365 to help self-treat your injuries.
3. Call your Branch Representative and report your injuries ASAP. NESC Staffing, Corp. may provide temporary alternative/transitional work opportunities to employees temporarily disabled by a work-related injury or illness. This may mean a modification of the present assignment, reassignment to different duties, or require a different work schedule. We take our responsibility as an employer very seriously. We go to great lengths and great expense to provide a safe working environment and Worker’s Compensation insurance for our employees. We deal promptly with meritorious and legitimate injuries and claims. However, we have extensive experience investigating and controverting fraudulent or malingering claims and will fight these types of claims with all available resources. I have read the above and understand it. Employee
