MARK ONLY THOSE SKILLS FOR WHICH YOU HAVE ON-JOB EXPERIENCE
HARDWARE PLATFORMS PROGRAMMING LANGUAGES/ COMMUNICATIONS COMMUNICATIONS, CONT. DESKTOP PUBLISHING/
DEV. TOOLS GRAPHICS
___MAINFRAME ___NOVELL NETWARE ___ROUTERS ________________
___DOS_______________________ ___INTRANETWARE ___QUARKXPRESS
_________________________ ___COBOL____________________ ___GROUPWISE _____________________________ ___FREEHAND
___ OTHER, MAINFRAME ___MANAGEWISE ___ILLUSTRATOR
___MIDRANGE ______________________________ ___WEB SERVERS______________ ___SWITCHES _______________ ___PHOTOSHOP
___DATABASES_______________ ______________________________ ___FRONTPAGE
_________________________ ______________________________ ______________________________ ____________________________ ___FRAMEMAKER
___SQL v._____________________ ___CNA ___PAGEMAKER
___UNIX ___ESQL ___CNE ___HUBS __________________ ___OTHER
_________________________ ___ODBC ___3.x ____________________________ ______________________________
___PC/DESKTOP ___PRO*C ___NT ___ANALYZERS ____________ ______________________________
___DESIGNER/DEVELOPER 2000 ___2000
_________________________ ___SAS ___XP _____________________________ ______________________________
_________________________ ___C++ ___MS-EXCHANGE ___NETWORK MONITORING __
___.NET ___LOTUS NOTES WEB DESIGN & DEVELOPMENT –
___OTHERS ___C# ___BANYAN VINES ____________________________ PLEASE LIST SKILLS AND TOOLS:
___VISUAL BASIC ___ETHERNET
_________________________ ___VB.NET ___TCP/IP ___NETWORK MANAGEMENT__
___VB SCRIPT ___HTTP ___________________
_________________________ ___HTML ___HTTPS _____________________________
___DHTML ___ATM ___________________
_________________________ ___PERL ___10 BASE T
___ASP ___LU 6.2 _____________________________ ___________________
_________________________ ___COLD FUSION ___BGP4 ___________________
___VISUAL STUDIO __________________ ___________________
_________________________ ___VISUAL STUDIO.NET
_________________________ I-9 ___ W-2 ___
LAST NAME ____________________________ FIRST NAME ________________________ M ________ PHONE __________________________________
ADDRESS __________________________________________ ____________________________ PHONE _________________________________
CITY/STATE _____________________________________ ZIP __________________ START DATE __________ E-MAIL
IS YOUR MAILING ADDRESS DIFFERENT? YES NO EMERGENCY CONTACT _________________________ PHONE ______________
AREAS YOU WILL NOT WORK? _______________________________________ JOBS YOU WILL NOT DO? ___________________________
DO YOU HAVE A CAR? YES NO
MARK ONLY THOSE SKILLS FOR WHICH YOU HAVE ON-JOB EXPERIENCE
CERTIFICATIONS POSITIONS/YEARS EXP. ___SOFTWARE QA ENGINEER
___SOFTWARE QA TESTER
NOVELL___CNA___CNE___ECNE ___ACCOUNT EXEC. ___SUPPLY CHAIN SPECIALIST
Staffing Solutions, LLC MICROSOFT___MCP___MCSE___MCSD ___APPLICATION DEVELOPMENT ___SYSTEMS ADMINISTRATOR
610 SW Broadway, Suite 500 CISCO___CCNA___CCNE___CCNP ___APPLICATION DEVELOPMENT ___SYSTEMS PROGRAMMER
Portland, Oregon 97205 ___A+ MANAGER ___TECHNICAL TRAINER
___PMP ___ARCHITECT (SOFTWARE) ___TECHNICAL WRITER
___BUSINESS ANALYST ___TELECOMMUNICATIONS SPECIALIST
T: 503.295.9948 OTHER SW______________________________ ___COMPUTER OPERATOR ___WEB DEVELOPER
800.834.9762 ___DATABASE ADMINISTRATOR
F: 503.295.9977 ________________________________________ ___DATABASE ANALYST
E: email@example.com ___DATABASE ARCHITECT ______________________________________
www.staffingsolutionsllc.com OTHER HW_____________________________ ___DATABASE DEVELOPER
___DESKTOP/PC SUPPORT ______________________________________
________________________________________ ___HARDWARE TECHNICIAN
___HELP DESK/TECH SUPPORT i ______________________________________
___HELP DESK/TECH SUPPORT II
INDUSTRIES ___HELP DESK/TECH SUPPORT iii
___I/S & I.T. MANAGER
___LEGAL ___INTERNET/INTRANET DEVELOPER
___MEDICAL ___NOC TECHNICIAN
___BANKING ___NETWORK ADMINISTRATOR
___INSURANCE ___NETWORK ENGINEER
___MANUFACTURING ___NETWORK MANAGER
___RETAIL/POS ___PROJECT MANAGER/LEAD
___TELECOMMUNICATIONS ___QA SPECIALIST/TEST
PLEASE ANSWER ALL QUESTIONS
1. Why are you seeking temporary employment? _____________________________________________________________________________
2. Are you looking for full time employment? Yes ___ No ___ Long term assignments? Yes ___ No ___
3. Please list name of person who referred you to us? __________________________________________________________________________
4. Have you ever been convicted of a crime? Yes ___ No___ If yes, when, where, explain
5. Have you ever been a defendant in a lawsuit alleging you committed any intentional act? Yes ___ No ___ If yes, when, where, explain
PLEASE LIST PREVIOUS & CURRENT TEMPORARY SERVICE EMPLOYMENT
Temp Service City From / To Pay Skill Companies / Industries Worked For
Education: Circle Highest Grade Completed:
High School 9 10 11 12 GED College 1 2 3 4 Grad School No Yes Degrees ______________ Other Schooling _______________________
LIST ANY OTHER SKILLS YOU HAVE: ________________________________________________________________________________________
PREVIOUS FULL TIME EMPLOYMENT (List last employer first) (We may also ask for additional job information and places you have lived.)
From To Company Name & Address Title &/or Duties Supervisor Phone Reason for Salary
As a condition of employment, you will be required to complete the U.S. Immigration and Naturalization Service Form I-9 and produce required original
documents establishing your identity and authorization to work.
CERTIFICATION UNDER PENALTIES OF FALSE STATEMENT-ACKNOWLEDGMENT OF AT WILL EMPLOYMENT
I certify that the answers given herein are true and complete to the best of my knowledge. I understand that employment may be terminated or denied me because
of false, incomplete or misleading information in my application or interview(s). I understand that nothing contained in this employment application or in the granting of an
interview creates an agreement for employment or any other benefit. No promises regarding employment have been made to me. If I accept an assignment, I understand that
unless stopped by you or your client, I will complete the assignment. I have the right to not accept an assignment or tell you I am no longer available for work, at any time
and for any reason or no reason and that you have the same right to terminate an assignment or not place me in an assignment for any reason or no reason.
RELEASE OF INFORMATION & AUTHORIZATION FOR CONSUMER REPORT
I authorize my employers, schools or persons named above to release to Staffing Solutions, LLC all information regarding my employment, salary, grades, job
performance, character and qualifications. I also agree that Staffing Solutions, LLC may obtain a "consumer report" under the Fair Credit Reporting Act. I authorize all
such parties who are contacted for information about me to release all such information about me without obligation or liability to me on account of such release.
DO NOT WRITE BELOW LINE
Exceed Meets EVALUATIONS:
INTERNAL OFFICE COMMENTS:
Professional Code of Conduct
I have read and received a copy of the Professional Code of Conduct/Employee
Orientation procedures from Staffing Solutions, LLC. I hereby agree to follow all procedures
and requirements if I accept employment through Staffing Solutions. I understand these terms
Code of Conduct
Staffing Solutions, LLC / K-Counsel®
610 SW Broadway, Suite 500
Portland, Oregon 97205
Phone 503-295-9948 Fax 503-295-9977
STAFFING SOLUTIONS, LLC -- A PROFESSIONAL CODE OF CONDUCT
EMPLOYEE ORIENTATION and COMPANY POLICIES
(Revised August 6, 2003)
Welcome to Staffing Solutions, LLC/K-Counsel®. You are an integral member of our
It is prestigious to work through Staffing Solutions, LLC/K-Counsel®. Why? We have a
commitment to our clients and temporaries to provide excellence in service, professionalism and
values of respect to all members of our community. Our reputation in this industry is well-
known; our management team is recognized by top law firms and corporations metro-wide.
We have a combined experience of over 100 years in law firm/corporate recruiting,
placement, administration, and Temporary Help Industry management and technical
recruiting and placement.
As our “temporary”, WE ARE YOUR EMPLOYER. We send you to our client and
we pay you. Your pay depends on your experience and the job requirements. We
also pay for your worker’s compensation coverage and unemployment insurance. By accepting
an assignment, you agree to the terms and policies below.
Your application for work must be accurate and truthful. We will discharge you if there is any
false or material misrepresentation on your application.
LENGTH OF EMPLOYMENT
By the nature of our business, your employment with us is “temporary” and “at will”. This
means you or we may end your employment, with or without notice, and with or without reason.
However, if you accept an assignment, we expect you to complete the assignment. Our client
may also end your assignment, with or without notice, and with or without reason.
WHAT WE EXPECT FROM OUR PROFESSIONALS
Attitude and Cooperation
• Be “of service” and demonstrate your willingness to perform the tasks in a timely
• Be pleasant, courteous and use proper business manners.
• If you are not certain on how to complete a requested task, ASK FOR DIRECTIONS.
• Business wardrobes are required for all assignments, unless otherwise specified.
Reliability and Responsibility
Arrive ON TIME
PERFORM THE TASKS OUR CLIENTS REQUEST, WHICH YOU AGREE TO DO
WHEN YOU ACCEPT THE JOB.
Change in Assignment or Given Client’s Property
We ask our clients not to assign you to other types of work without our prior approval. If that
occurs, we expect you to call our office BEFORE doing any work that is not in your current job
description. EXAMPLES: lifting and moving boxes; driving, etc. We want you to call us also
if you are given any client property, such as a credit card, ability to charge on client’s account,
laptop computer, cell phone, keys or other similar items. You agree to return all items, including
keys, immediately upon the termination of the assignment. We may require you to sign a specific
agreement about the items use and return.
In addition to arriving at your assignment ON TIME, PROFESSIONALS observe our client’s
business hours. Do not request to change your hours without advance approval from our office.
We will make any changes through our client. COMPLETE THE ASSIGNMENT as you
agreed. Any employee who does not show for an assignment or leaves without permission
before completion, WILL NOT be considered for future assignments.
Clients’ Information Systems
While working for our client you will most likely use one of their Information Systems
(computer, telephone, voice mail, e-mail or Internet). Remember these systems and their
contents are our client’s assets. You should not have any expectation of privacy. You are not to
download or take any data or programs from our client. You will not change or block any
password on any information system. Good judgment should always be employed in using any
information systems. Please take special care to avoid any files, messages or data that would be
inconsistent with our and our client’s policies, such as those prohibiting discrimination and
harassment. Avoid any jokes or comments that could offend someone on the basis of gender,
race, religion, national origin, disability and sexual orientation. Do not visit or download
material from any sexually graphic web sites.
Confidential Information and Trade Secrets
All information you may have access to from our client or its customer, including any non public
personal information, is confidential and shall not be disclosed to anyone unless our client
consents. Trade secrets of our client shall be held in confidence All work you perform for our
client is “work for hire” and our client shall have all ownership interest in the work or product.
EVALUATING YOUR PERFORMANCE
Staffing Solutions, LLC makes a special effort to match your skills, experience and
qualifications with the needs of our clients. You will be evaluated by our clients upon
completion of the assignment. These evaluations will be part of your work record and will be
considered for future assignments.
TIME CARDS, OVERTIME, RELEASE TO OTHERS
It is your responsibility to submit a properly completed time card, signed by an
authorized supervisor and your signature. If you have trouble doing this, let us
know immediately. No paycheck will be released to another person without your
written permission. Overtime begins according to state law; for Oregon it starts
after 40 hours worked in one week. You must have prior approval from your
immediate supervisor who must notify our office before Overtime is worked.
Please see Sample Time Card for proper completion. Mark the time you start
and stop work each day. Record your time to the nearest 1/4 hour. Subtract the
time spent for lunch, then add up the total time for the week. You sign the card, then have your
supervisor sign it.
Procedure: Fax your time card to us on Friday and then drop your time card off on Friday (for
the current work week) or no later than the following Monday. If you prefer to mail your time
card, we cannot guarantee receipt by Monday for processing. We must have time cards no later
than 12:00 PM, on Monday FOR THE PRECEDING WORK WEEK. If you have problems, let
us know immediately. We encourage you to physically come in for Time Card Processing as
well to pick up your pay check.
If we receive your time card by Monday noon, you will be paid on Friday for the preceding work
week. If we receive your time card after Monday noon, your pay day will be the second Friday
following the time card’s receipt. Payroll checks will be ready by 12 noon on Friday. We will
hold the checks until 4:40 PM on Fridays to allow for travel time, as well as the opportunity to
see you and share information about future job assignments. After 4:40 PM, we mail them. If
you cannot come to the office to pick up your check and you notify us in writing, we will mail
your check on Thursday night.
TEMP TO HIRE
DO NOT SOLICIT OUR CLIENTS for full time positions. If they want to hire you for full-
time work, they will contact us. Our conversion policy from temporary work to full-time may
vary with each client. If you accept an assignment through us and are offered a full-time
position with that client, you may be required to remain on our payroll for an additional period of
time depending on our agreement with our client.
CALL US WITHIN THE FIRST 15 MINUTES IF:
• You cannot report to work.
• You are offered a job.
• Your assignment ends.
• You are going to be late.
• You are sick.
• You have accepted another job.
• You have any problems at work.
• Your supervisor wants to change your job description.
• You become injured on the job.
• You are unable to perform the task requested.
Our office hours are 8:00 AM to 5:00 PM, Monday through Friday. If you need to reach us
before or after office hours, you may leave a message on our voice mail.
Our telephone # is: 503 295-9948. Our Fax # is: 503 295-9977.
You must IMMEDIATELY report TO US, any accident on the job that requires medical
treatment or time off from work.
Our objective is a strong “Return to Work” commitment for injured employees. If you become
injured, you will be advised of our Return to Work - Light Duty requirements.
Once you have registered and your skills have been evaluated, check in at least once a week; we
need to know where you can be reached for assignments. Our clients call us all day long, and
many future assignments are placed and special requests are made for specific temporaries--so it
is important we have a working telephone number for you at all times.
Please notify us by phone if you are no longer active or wish to work. Your status will be posted
on your application as INACTIVE. If you change your status to ACTIVE within one year, you
will not have to be retested, but you might need a new W-4. Temporary employment gives you
flexibility, but if you turn us down on a number of assignments or fail to check in weekly when
not working, we will consider you to be inactive.
CURRENT ADDRESS & TELEPHONE (OR MESSAGE PHONE)
You are responsible to notify us in writing if you change your address or phone number. This
will be part of your record and necessary to process W-2's. If you request your paycheck to be
mailed, we cannot guarantee prompt delivery without a proper address. PLEASE NOTE: year
end W-2's, sent in January, cannot be delivered without a current address, so if you change your
address after leaving our employ please keep us informed.
Policy. We will not allow, nor will you engage in, any form of harassment of any
individual or any such conduct that has the purpose or effect of interfering with an individual's
work performance or creating an intimidating, hostile, or offensive work environment because
of that person's sex, race, religion, creed, color, age, national origin, ancestry, marital status,
veteran status, disability, sexual orientation, or any other status protected under applicable
federal, state or local law. Respect for the dignity and worth of others should be the guiding
principle for our relations with each other.
Prohibited Conduct. Prohibited conduct includes, but is not limited to, racial, ethnic or
religious slurs or jokes. It includes unwelcome sexual advances, requests for sexual favors,
physical touching, or the granting or withholding of benefits of employment (e.g., pay,
promotion, time off) in response to sexual conduct when (1) submission is made either explicitly
or implicitly a term or condition of an employee's employment, (2) submission to or rejection of
such conduct by an employee influences employment decisions affecting the employee, or (3)
the conduct has the purpose or effect of interfering with an employee's work performance or
creating an intimidating, hostile or offensive work environment.
Prohibited conduct may be oral, written, visual or physical in nature. More subtle forms
of behavior, such as offensive posters, cartoons, comments and jokes of a sexual, religious, racial
or ethnic nature also may constitute harassment when they create or contribute to an
intimidating, hostile or offensive work environment.
Implementation Guidelines. If you believe that you are a victim of sexual, racial or other
social harassment by any of our employees, our customer or their employees, you must report the
circumstances as soon as possible to the person in our company who placed you in the
assignment or any of our staff with whom you feel comfortable. If the complaint is about any
of our staff, then an owner should be contacted.
We will investigate all complaints of harassment to the extent possible based on the
information available about the circumstances. While the complaint and any information
gathered in an investigation is considered confidential information, employees should be
cautioned that pursuing an investigation may require or lead to disclosure of the identity of those
connected to the complaint or to disclosure of information which could lead to the identification
of persons connected to the complaint. If you report any social harassment, no adverse
employment decision will be made against you for making such a report.
Work 1000 hours in a calendar year (January -December), receive 5 days’ pay at average pay
rate earned in above period.
Work 1000 hours in the twelve months prior to the holiday and receive $100 for
New Year’s Memorial Day July 4 Labor Day Thanksgiving Christmas
You must also have worked the day BEFORE the holiday and the day AFTER the holiday to
Payroll Service Employees
If you are a payroll service employee, you do not qualify for vacation pay or holiday bonus
unless our client authorizes such payment.
You will become eligible for health insurance when you first start to work for us. We do not
administer or contribute to this plan, it is done on an individual basis through JL Barnes and
Fortis Insurance. You will receive a brochure with your first paycheck.
Profit Sharing Pension Plan
Staffing Solutions, LLC funds its Profit Sharing Pension Plan. You are not required to make a
contribution. You will be notified by the Plan Administrator upon qualifying for the plan and
what contribution has been made for your account. The plan is governed by the plan document,
which shall control at all times.
STAFFING SOLUTIONS, LLC – DRUG TESTING POLICY
Staffing Solutions, LLC and its clients, have a strong commitment to their employees to provide
a safe environment and to promote high standards of employee health. Consistent with the spirit
and intent of this commitment, many of our client’s have established a policy on drug and
alcohol use. Their goal is to establish and maintain a work environment that is completely free
from the effects on employees of alcohol and drug use. In all respects our policy will be the
same as our client’s policy, unless parts or all of our client’s policy is not legal.
Pre-employment drug screening of employees for unlawful drug use is required by some of our
clients. We will notify you if you are being considered for an assignment with one of these
clients. At that time, if available, you will be given the client's drug policy. You will be required
to follow that policy as a condition of employment with that client.
We will be doing the test on behalf of our client. It will be a urine sample taken on our premises.
As a condition of employment with our client, you will be required to give a urine sample, and
certify that it is your urine taken at the time the kit is given to you.
In the event of an inconclusive test for drugs, the sample will be sent to the laboratory for
conformation, in accordance with the laboratory’s procedures.
If the laboratory confirms an inconclusive screening test as positive, you will not be eligible for
the job with the client who requested the test.
Drug test results, inconclusive, positive or negative, and the fact that a test was performed, will
be kept as confidential as possible under all the factual circumstances. Our client of course must
be notified. Further testing, second testing, what constitutes a refusal to take the test, the extent
to which other legally prescribed medications and any other matters involving the tests will be
conducted in accordance with the policy of our client.
FUTURE EMPLOYMENT WITH US
If your test is confirmed positive by the laboratory, we will not consider you for placement with
any of our clients for a period of six months.
IN THE OFFICE
In case of an accident or emergency dial 911
Your address at your assignment is: (you should fill this in below)
YOUR DESK and CHAIR. DO NOT be afraid to adjust your desk chair, so it is in an
ergonomic correct position. Your chair in relation to your work, or computer should be adjusted
so it looks like the figure below.
Five simple steps for healthy computing:
Using these guidelines and diagram, work together with
your supervisor to solve your ergonomic programs.
• Make sure your monitor and keyboard are positioned
• Make sure if you have an ergonomic designed chair, that
it is adjusted correctly.
• Make sure that you have adequate and appropriate
• Do quick exercises to keep your muscles relaxed.
• Move your eyes frequently and focus them away from the screen.
SLIP AND FALL. Watch where you walk! Watch for loose carpet, electrical boxes, cords,
boxes or anything you could trip over. Do Not use stools without someone to steady you. If you
are at all uncertain as to how to use a small ladder or stool, ASK FOR HELP. Do Not lift heavy
boxes or equipment over your head without some help.
HAZARD COMMUNICATION. Generally, most offices do not have hazardous substances.
Whiteout, toner and other copier fluids are what you will generally see. If you have any
problems with these substances, please contact your supervisor. If you come into contact with
any other substance which you believe may be hazardous or harmful to you, let your supervisor
know immediately. Forms are available or will be obtained which describe the substance and its
LIFTING BOXES OR EQUIPMENT. Do Not lift more than you are comfortable with. We
recommend not lifting more than ten (10) pounds from the floor to a table nor more than five (5)
pounds from the table to an overhead shelf. When lifting please follow the technique which
BASIC LIFTING & LOWERING TECHNIQUE
• Plan the lift (route, obstacles, doors)
• Estimate the weight of the object (heft/tilt test)
• Spread feet apart (about shoulder width)
• Bend your knees
• Tighten stomach muscles
• Head up & chin out
• Securely grip the load
• Keep the load close to the body
• Lift slowly & evenly, avoid rapid, jerky motions
• Avoid simultaneous lifting and twisting
VIOLENCE. While we hope no violence will take place, you must understand that neither we
nor our client can prevent all violence. You and we need to work together to reduce the risk for
such violence. If at any time you feel uncomfortable with a co-employee, customer/client or
other person, please advise your supervisor. If you work late, you should notify your supervisor.
Ask if they will have someone escort you to your car. If you apply for or obtain a protective or
restraining order which lists our or our client’s premises as being protected areas, provide us
with a copy. We understand the sensitivity of the information requested and we will our best to
keep it confidential. We will have to notify our client. If you would like more information,
please ask for our supplemental brochure about "Warning Signs of Potentially Violent
Individuals" and "Personal Conduct to Minimize Violence."
GENERAL SAFETY. Observe good housekeeping around your desk and the equipment you
• Do not perform any action that causes hazards or makes any equipment unsafe.
• Keep boxes, files, etc. out of walkways so people won't trip.
• Keep desk drawers closed. Keep file cabinet doors closed.
• If using a shredder, be careful of dangling jewelry, ties and hair.
REPORTING ACCIDENTS AND INJURIES. Any work related accident or injury, must be
reported to us immediately. If you cannot, then ask someone to tell us.
LEGAL ASSISTANTS, LAW CLERKS AND SUPERVISED LAWYERS
You may be performing legal research, writing and case review for our client. You must follow
the guidelines which follow. If you are asked to do something contrary to the guidelines, you are
required to call us to explain the situation before you proceed. Should you have any questions,
• Your work is reviewed and supervised by a lawyer;
• You make no strategy or case decisions;
• You do not hold yourself out to any client as a lawyer;
• You sign no letters, pleadings or briefs;
• You attend no depositions as the lawyer of record;
• You make no court appearances as the lawyer of record;
• You do not use the title “lawyer,” “attorney at law,” “counselor,” “attorney,” or “J.D.” on
any correspondence or documents; and
• You are not listed in the firm name or on the firm letterhead as a lawyer or firm member.
OTHER DOS AND DO NOTS
• Direct your legal research memos to your supervising lawyer and never send them
directly to the client;
• Do not participate in or conduct client interviews;
• Do not discuss the case, formally or informally with the client. This includes discussion
by phone and in person; and
• Do not correspond with the client.
If you are a lawyer working as either an assistant or law clerk, without being admitted to the
Oregon State Bar and having Professional Liability Fund insurance coverage, it is very
important that you follow the guidelines. These guidelines are adapted from exemptions to the
Oregon State Bar’s Professional Liability Fund. If you have any questions about Professional
Liability Fund coverage or the activities which you can do as a lawyer exempt from such
coverage, please contact the Professional Liability Fund 503-639-6911 or 1-800-452-1639.
TECHNICAL SERVICE EMPLOYEE
Throughout this Agreement, Staffing Solutions, LLC, employer, will be referred to as "we", "us" or
"our" and the Employee will be referred to as "you" or "your". “Our client” will be the entity to which
you are referred for interview or work and any of their customers for whom you are on a project or on
whose site you may actually work. In consideration of our employing you, sending you for an interview
or assigning you for temporary work at our client, you and we agree as follows:
1. Reporting/Interview Date and Work Rules. You agree to report to our client for work on the day
scheduled, "Reporting Date," and work on the assignment until it is completed or until it is terminated. If
you are sent for an interview you agree to attend the interview as scheduled and if offered the temporary
assignment you will report on the "Reporting Date." You agree to all the terms and conditions of this
agreement. You further agree to follow all work rules, safety rules and policies of our client.
2. Compensation. If you are employed by us, we will pay you the agreed rate of pay for the hours
you actually work for our client on our regularly scheduled pay day. We will pay you the overtime
actually worked and authorized by our customer in advance of your working the overtime.
3. Time Cards. You are responsible for keeping your time card for all the hours you work. Once
the time card or hours are called in to us, you agree not to claim further hours later.
4. Return of Our and Our Client’s Equipment. In the event we or our client (you will notify us
immediately in this event) allow you to use a credit card or other equipment for use on the assignment for
our or their behalf, you agree that such credit card and other equipment is our or our client’s property.
You further agree that such shall be used only for our or our client’s business purposes. When the
assignment terminates or we or our client requests, you will promptly return the credit card and
equipment to us or our client. In the event you do not return the equipment or have used the credit card
for other than our or our client’s business you agree to pay us or our client for the non business related
items and/or the current fair market value to replace the equipment. You further agree that we may
enforce this provision and we will be entitled to all our costs of collection including attorney fees, court
costs, investigation fees, and other related costs of collection. You also agree to pay for the time we
spend internally in preparing this collection matter at the same rate as you were paid on the assignment.
5. Confidential Matters. During your employment with us, you will have access to and become
familiar with various trade secrets and other sensitive or confidential information (hereafter called
"Confidential Matters") of ours and our client. Such "Confidential Matters", all of which are owned by us
or our client, includes, but is not limited to, the following: protected trade secrets, information with
respect to inventions, designs, formulas, tools, equipment, unpublished written materials, plans,
processes, costs, methods, systems, improvements, enhancements, modifications, technical or business
innovations and any and all expressions of computer programs, manuals, data bases, and all forms of
computer hardware, firmware, and software; names and addresses of our client's customers, including non
public personal information of our client's customers, employees, suppliers or other matters; systems for
recruitment or for the operation of our or our client's business; and any and all computer generated or
computer stored information, data files, prints, descriptions, systems, software, or documentation and
anything else provided by us or our client. You agree to hold in strict confidence and not to disclose any
"Confidential Matters", directly or indirectly, to anyone, nor to use them in any way, either during your
employment with us or at any time after its termination, except as may be required in the course of your
performing services hereunder, or if we give our prior written consent.
Page - 1 EMPLOYMENT AGREEMENT - TECHNICAL SERVICE EMPLOYEE
All formulas, files, records, reports, programs, manuals, tapes, card decks, listings, software,
systems, drawings, specifications, agreements, equipment and similar items or enhancements,
modifications, or improvements, customer and supplier lists, relating to our business, whether prepared by
you or through some other source, will remain our exclusive property and you will not remove from our
premises any such items under any circumstances without our prior written consent. You also agree that,
in the event of the termination of your employment with us, you will immediately return all such items
which may be in your possession and if requested by us you will state in writing that all such items were
6. Developments. You agree that you will promptly and fully disclose to us in writing any
"Developments". "Developments" include, but are not limited to, new recipes, new formulas, new
processes, new customers, new employees, data, drawings, electronic recordings, writings, information,
inventions, designs, ideas, improvements, enhancements, modifications, technical or business
innovations, and discoveries, whether or not such can be patented or copyrighted, which relate in any way
to your work for us or our client, or to our or our client’s business or are suggested by such matters and
which you may make, record, write, conceive, develop, first reduce to practice or discover, alone or with
others during your employment with us (regardless of whether made, recorded, written, conceived,
developed, first reduced to practice or discovered during working hours) and after the termination of your
employment with us.
All such "Developments" will become our or our client’s exclusive property and you agree to
assist us (at no cost to you) during your employment or at any time or times thereafter in executing
documents and doing any other things necessary to obtain patents, copyrights, or other legal protection in
our or our client’s name and to otherwise vest complete right, title and interest in us or our client to any
such "Developments" or any other exclusive property of ours or our client.
You represent and warrant that there are at present no recipes, formulas, processes, recordings,
writings, inventions, improvements, or discoveries -- not included in a copyright, copyright application,
patent, or patent application -- which were recorded, written, conceived, invented, made, or discovered by
you before entering into this Agreement and which you desire to remove from the provisions of this
Agreement, except those specifically set forth by attachment hereto.
7. Additional Documents and Assignment. If we so request, you also agree to execute and deliver
during your employment or at any time or times thereafter any such agreements or documents, pertaining
to any such "Developments" and/or "Confidential Matters", as we may request.
These Developments and Confidential Matters provisions shall be for our and/or our client’s
benefit. We or they shall have all rights and remedies to enforce any and all provisions. We also reserve
the right to assign this agreement and all the provisions herein to any other person or entity.
8. Obligations During Employment with Us and After Interview or Termination. During any
assignment with us and/or for a period of ONE HUNDRED EIGHTY (180) days after the later of, any
interview or terminated assignment, you agree that 1) you will not work for, accept employment from, nor
will you solicit employment with our client (remembering this also includes our client’s customer,) and
2) you will not accept employment with another employer for an assignment to work at our client's
premises or on a project for our client which may not be on its premises. You also agree that any period
of violation or time required for litigation to enforce this provision will not be included in this 180 day
period. You acknowledge that we have spent time in procuring this client and our client has spent time
procuring its customer, interviewing or reviewing your qualifications for the temporary job and that this is
sufficient consideration to enforce this provision. You and we both recognize that, if the above provisions
are violated, remedies which would typically be available to us for contract breach would be inadequate.
Therefore, you and we have agreed that we have the right to obtain injunctive or other equitable relief
against you, and any other person who may be involved or connected with you, in the event that these
provisions are breached. These rights will be in addition to any other rights which we may have under
law. If a violation occurs under this paragraph we will have the right to obtain attorney fees and cost
from you, to be set by the court, if any action or suit is necessary to enforce this provision.
Page - 2 EMPLOYMENT AGREEMENT - TECHNICAL SERVICE EMPLOYEE
9. Other Agreements. You represent to us that you have made no other agreements which would
stop you from entering into this agreement. You represent that if you are bound by an agreement not to
divulge any confidential information of another employer you will notify us of its content and extent.
10. Survival of Certain Provisions; Remedies. You and we have specifically agreed that the above
Developments, Confidential Matters, and Obligations During Employment with Us and After Interview
or Termination provisions of this Agreement are considered as agreements independent of any other
provisions of your employment with us, and the existence of a claim which you might allege against us,
whether based on this Agreement or otherwise, will not prevent us from enforcing these provisions.
Further, relying upon your agreement to these provisions, we are placing you in a position of great trust
and confidence. You and we both recognize that, if the above provisions are violated, remedies which
would typically be available to us for contract breach would be inadequate. Therefore, you and we have
agreed that we have the right to obtain injunctive or other equitable relief against you, and any other
person who may be involved or connected with you, in the event that these provisions are breached.
These rights will be in addition to any other rights which we may have under law.
In the event that we institute legal action against you to enforce the above Developments,
Confidential Matters and/or Obligations During Employment with Us and After Interview or Termination
provisions, and in the event that such action leads to or results in a court decision or settlement in our
favor, you agree to fully reimburse us for our legal fees and related costs involved in our pursuing such
action against you.
11. No Change In "At Will" Employment. You understand that this Agreement is not intended to
alter the "at will" nature of our employment relationship.
You and we have executed this Agreement, intending to be legally bound by it.
Staffing Solutions, LLC
Page - 3 EMPLOYMENT AGREEMENT - TECHNICAL SERVICE EMPLOYEE
Complete all worksheets that apply. However, you dividends, consider making estimated tax
Form W-4 (2009) may claim fewer (or zero) allowances. For regular
wages, withholding must be based on allowances
payments using Form 1040-ES, Estimated Tax
for Individuals. Otherwise, you may owe
Purpose. Complete Form W-4 so that your you claimed and may not be a flat amount or additional tax. If you have pension or annuity
employer can withhold the correct federal income percentage of wages. income, see Pub. 919 to find out if you should
tax from your pay. Consider completing a new adjust your withholding on Form W-4 or W-4P.
Head of household. Generally, you may claim
Form W-4 each year and when your personal or head of household filing status on your tax Two earners or multiple jobs. If you have a
financial situation changes. return only if you are unmarried and pay more working spouse or more than one job, figure
Exemption from withholding. If you are than 50% of the costs of keeping up a home the total number of allowances you are entitled
exempt, complete only lines 1, 2, 3, 4, and 7 for yourself and your dependent(s) or other to claim on all jobs using worksheets from only
and sign the form to validate it. Your exemption qualifying individuals. See Pub. 501, one Form W-4. Your withholding usually will
for 2009 expires February 16, 2010. See Exemptions, Standard Deduction, and Filing be most accurate when all allowances are
Pub. 505, Tax Withholding and Estimated Tax. Information, for information. claimed on the Form W-4 for the highest
Note. You cannot claim exemption from Tax credits. You can take projected tax paying job and zero allowances are claimed on
withholding if (a) your income exceeds $950 credits into account in figuring your allowable the others. See Pub. 919 for details.
and includes more than $300 of unearned number of withholding allowances. Credits for Nonresident alien. If you are a nonresident
income (for example, interest and dividends) child or dependent care expenses and the alien, see the Instructions for Form 8233
and (b) another person can claim you as a child tax credit may be claimed using the before completing this Form W-4.
dependent on their tax return. Personal Allowances Worksheet below. See
Pub. 919, How Do I Adjust My Tax Check your withholding. After your Form W-4
Basic instructions. If you are not exempt, takes effect, use Pub. 919 to see how the
complete the Personal Allowances Worksheet Withholding, for information on converting
your other credits into withholding allowances. amount you are having withheld compares to
below. The worksheets on page 2 further adjust your projected total tax for 2009. See Pub.
your withholding allowances based on itemized Nonwage income. If you have a large amount 919, especially if your earnings exceed
deductions, certain credits, adjustments to of nonwage income, such as interest or $130,000 (Single) or $180,000 (Married).
income, or two-earner/multiple job situations.
Personal Allowances Worksheet (Keep for your records.)
A Enter “1” for yourself if no one else can claim you as a dependent A
● You are single and have only one job; or
B Enter “1” if: ● You are married, have only one job, and your spouse does not work; or B
● Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.
C Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or
more than one job. (Entering “-0-” may help you avoid having too little tax withheld.) C
D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return D
E Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) E
F Enter “1” if you have at least $1,800 of child or dependent care expenses for which you plan to claim a credit F
(Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)
G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.
● If your total income will be less than $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
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
For accuracy, ● If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions
complete all and Adjustments Worksheet on page 2.
worksheets ● 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
that apply. $40,000 ($25,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld.
● If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.
Cut here and give Form W-4 to your employer. Keep the top part for your records.
Form W-4 Employee’s Withholding Allowance Certificate OMB No. 1545-0074
Department of the Treasury
Internal Revenue Service
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. 2009
1 Type or print your first name and middle initial. Last name 2 Your social security number
Home address (number and street or rural route) 3
Single Married Married, but withhold at higher Single rate.
Note. If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.
City or town, state, and ZIP code 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 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 6 $
7 I claim exemption from withholding for 2009, 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.
(Form is not valid unless you sign it.) Date
8 Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.) 9 Office code (optional) 10 Employer identification number (EIN)
For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 10220Q Form W-4 (2009)
Form W-4 (2009) Page 2
Deductions and Adjustments Worksheet
Note. Use this worksheet only if you plan to itemize deductions, claim certain credits, adjustments to income, or an additional standard deduction.
1 Enter an estimate of your 2009 itemized deductions. These include qualifying home mortgage interest,
charitable contributions, state and local taxes, medical expenses in excess of 7.5% of your income, and
miscellaneous deductions. (For 2009, you may have to reduce your itemized deductions if your income
is over $166,800 ($83,400 if married filing separately). See Worksheet 2 in Pub. 919 for details.) 1 $
$11,400 if married filing jointly or qualifying widow(er)
2 Enter: $ 8,350 if head of household 2 $
$ 5,700 if single or married filing separately
3 Subtract line 2 from line 1. If zero or less, enter “-0-” 3 $
4 Enter an estimate of your 2009 adjustments to income and any additional standard deduction. (Pub. 919) 4 $
5 Add lines 3 and 4 and enter the total. (Include any amount for credits from Worksheet 8 in Pub. 919.) 5 $
6 Enter an estimate of your 2009 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 $3,500 and enter the result here. Drop any fraction 8
9 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 (or from line 10 above if you used the Deductions and Adjustments Worksheet) 1
2 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if
you are married filing jointly and wages from the highest paying job are $50,000 or less, do not enter more
than “3.” 2
3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter
“-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet 3
Note. If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4–9 below to calculate the additional
withholding amount necessary to avoid a year-end tax bill.
4 Enter the number from line 2 of this worksheet 4
5 Enter the number from line 1 of this worksheet 5
6 Subtract line 5 from line 4 6
7 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here 7 $
8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed 8 $
9 Divide line 8 by the number of pay periods remaining in 2009. For example, divide by 26 if you are paid
every two weeks and you complete this form in December 2008. Enter the result here and on Form W-4,
line 6, page 1. This is the additional amount to be withheld from each paycheck 9 $
Table 1 Table 2
Married Filing Jointly All Others Married Filing Jointly All Others
If wages from LOWEST Enter on If wages from LOWEST Enter on If wages from HIGHEST Enter on If wages from HIGHEST Enter on
paying job are— line 2 above paying job are— line 2 above paying job are— line 7 above paying job are— line 7 above
$0 - $4,500 0 $0 - $6,000 0 $0 - $65,000 $550 $0 - $35,000 $550
4,501 - 9,000 1 6,001 - 12,000 1 65,001 - 120,000 910 35,001 - 90,000 910
9,001 - 18,000 2 12,001 - 19,000 2 120,001 - 185,000 1,020 90,001 - 165,000 1,020
18,001 - 22,000 3 19,001 - 26,000 3 185,001 - 330,000 1,200 165,001 - 370,000 1,200
22,001 - 26,000 4 26,001 - 35,000 4 330,001 and over 1,280 370,001 and over 1,280
26,001 - 32,000 5 35,001 - 50,000 5
32,001 - 38,000 6 50,001 - 65,000 6
38,001 - 46,000 7 65,001 - 80,000 7
46,001 - 55,000 8 80,001 - 90,000 8
55,001 - 60,000 9 90,001 - 120,000 9
60,001 - 65,000 10 120,001 and over 10
65,001 - 75,000 11
75,001 - 95,000 12
95,001 - 105,000 13
105,001 - 120,000 14
120,001 and over 15
Privacy Act and Paperwork Reduction Act Notice. We ask for the information on You are not required to provide the information requested on a form that is
this form to carry out the Internal Revenue laws of the United States. The Internal subject to the Paperwork Reduction Act unless the form displays a valid OMB
Revenue Code requires this information under sections 3402(f)(2)(A) and 6109 and control number. Books or records relating to a form or its instructions must be
their regulations. Failure to provide a properly completed form will result in your retained as long as their contents may become material in the administration of
being treated as a single person who claims no withholding allowances; providing any Internal Revenue law. Generally, tax returns and return information are
fraudulent information may also subject you to penalties. Routine uses of this confidential, as required by Code section 6103.
information include giving it to the Department of Justice for civil and criminal The average time and expenses required to complete and file this form will vary
litigation, to cities, states, the District of Columbia, and U.S. commonwealths and depending on individual circumstances. For estimated averages, see the
possessions for use in administering their tax laws, and using it in the National instructions for your income tax return.
Directory of New Hires. We may also disclose this information to other countries If you have suggestions for making this form simpler, we would be happy to hear
under a tax treaty, to federal and state agencies to enforce federal nontax criminal from you. See the instructions for your income tax return.
laws, or to federal law enforcement and intelligence agencies to combat terrorism.
OMB No. 1615-0047; Expires 06/30/08
Department of Homeland Security Form I-9, Employment
U.S. Citizenship and Immigration Services Eligibility Verification
Please 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 eligible 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 First Middle Initial Maiden Name
Address (Street Name and Number) Apt. # Date of Birth (month/day/year)
City State Zip Code Social Security #
I attest, under penalty of perjury, that I am (check one of the following):
I am aware that federal law provides for A citizen or national of the United States
imprisonment and/or fines for false statements or A lawful permanent resident (Alien #) A
use of false documents in connection with the An alien authorized to work until
completion of this form.
(Alien # or Admission #)
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
Expiration Date (if any):
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 eligible 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
Business or Organization Name and Address (Street Name and Number, City, State, Zip Code) Date (month/day/year)
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 eligibility.
Document Title: Document #: Expiration Date (if any):
l attest, under penalty of perjury, that to the best of my knowledge, this employee is eligible 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. 06/05/07) N
LISTS OF ACCEPTABLE DOCUMENTS
LIST A LIST B LIST C
Documents that Establish Both Documents that Establish Documents that Establish
Identity and Employment Identity Employment Eligibility
Eligibility OR AND
1. U.S. Passport (unexpired or expired) 1. Driver's license or ID card issued by 1. U.S. Social Security card issued by
a state or outlying possession of the the Social Security Administration
United States provided it contains a (other than a card stating it is not
photograph or information such as valid for employment)
name, date of birth, gender, height,
eye color and address
2. Permanent Resident Card or Alien 2. ID card issued by federal, state or 2. Certification of Birth Abroad
Registration Receipt Card (Form local government agencies or issued by the Department of State
I-551) entities, provided it contains a (Form FS-545 or Form DS-1350)
photograph or information such as
name, date of birth, gender, height,
eye color and address
3. An unexpired foreign passport with a 3. School ID card with a photograph 3. Original or certified copy of a birth
temporary I-551 stamp certificate issued by a state,
county, municipal authority or
outlying possession of the United
States bearing an official seal
4. An unexpired Employment 4. Voter's registration card 4. Native American tribal document
Authorization Document that contains
(Form I-766, I-688, I-688A, I-688B) 5. U.S. Military card or draft record 5. U.S. Citizen ID Card (Form I-197)
5. An unexpired foreign passport with 6. Military dependent's ID card 6. ID Card for use of Resident
an unexpired Arrival-Departure Citizen in the United States (Form
Record, Form I-94, bearing the same 7. U.S. Coast Guard Merchant Mariner I-179)
name as the passport and containing Card
an endorsement of the alien's
nonimmigrant status, if that status 8. Native American tribal document 7. Unexpired employment
authorizes the alien to work for the authorization document issued by
employer 9. Driver's license issued by a Canadian DHS (other than those listed under
government authority List A)
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
Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274)
Form I-9 (Rev. 06/05/07) N Page 2
LISTS OF ACCEPTABLE DOCUMENTS
LIST A LIST B LIST C
Documents that Establish Both Documents that Establish Documents that Establish
Identity and Employment OR Identity AND Employment Eligibility
1. Driver’s license or ID card 1. U.S. social security card issued
1. U.S. Passport (unexpired or
expired) issued by a state or outlying by the Social Security
possession of the United States Administration (other than a
provided it contains a card stating it is not valid for
2. Certificate of U.S. Citizenship photograph or information such employment)
(INS Form N-560 or N-561) as name, date of birth, sex,
height, eye color, and address
2. Certification of Birth Abroad
3. Certificate of Naturalization 2. ID card issued by federal, state, issued by the Department of
(INS Form N-550 or N-570) or local government agencies or State (Form FS-545 or Form
entities provided it contains a DS-1350)
photograph or information such
4. Unexpired foreign passport,
as name, date of birth, sex,
with I-551 stamp or attached
INS Form I-94 indicating height, eye color, and address
unexpired employment 3. Original or certified copy of a
authorization 3. School ID card with a birth certificate issued by a
photograph state, county, municipal
authority or outlying possession
5. Alien Registration Receipt Card of the United States bearing an
4. Voter’s registration card
with photograph (INS Form official seal
I-151 or I-551) 5. U.S. Military card or draft record
6. Military dependent’s ID card 4. Native American tribal document
6. Unexpired Temporary Resident
Card (INS Form I-688)
7. U.S. Coast Guard Merchant
5. U.S. Citizen ID Card (INS Form
7. Unexpired Employment
8. Native American tribal document I-197)
Authorization Card (INS Form
9. Driver’s license issued by a
Canadian government authority 6. ID Card for use of Resident
8. Unexpired Reentry Permit (INS
Citizen in the United States
Form I-327) For persons under age 18 who (INS Form I-179)
are unable to present a
document listed above:
9. Unexpired Refugee Travel
Document (INS Form I-571)
7. Unexpired employment
10. Unexpired Employment 10. School record or report card authorization document issued
Authorization Document issued by the INS (other than those
by the INS which contains a 11. Clinic, doctor, or hospital record listed under List A)
photograph (INS Form I-688B)
12. Day-care or nursery school
Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274)
Form I-9 (Rev. 11-21-91) N
We at Staffing Solutions, LLC appreciate you filling out all our forms. Each is used for a
particular purpose to help us place you in an appropriate position and make sure your pay is
accurate. This form is used by our accounting department and to see if you have reached the
minimum age to be considered under our pension plan. Please fill out the top portion. Thank
This form is filed separately from your employment application.
CELL PHONE#: (_____)_________________________________
SOCIAL SECURITY #: ________-_______________-_____________
DATE OF BIRTH: ______________________
DO NOT WRITE BELOW THIS LINE FOR OFFICE USE ONLY
DATE OF HIRE: ______________ CODE: _____________ Payroll ID: _____________
DATE OF TERMINATION: __________________________
REHIRE DATE: _____________________ Is new paperwork on file? Yes No
INFORMATION rev 2008.doc
ACCOUNTING INFORMATION rev 2008ACCOUNTING INFORMATION rev 2008
To ensure you receive your paycheck timely, the following two steps are critical:
1. On Friday, submit your timecard to our office one of the following ways:
Deliver your timecard to our office
Fax your timecard to 503‐295‐9977
Scan and e‐mail your timecard to firstname.lastname@example.org . If you email your
timecard, you will receive a reply message of “Thank You” so that you will know it was received.
2. The original copy should then be delivered to our office or put in the mail.
Please Note: In order for us to complete the processing of your paycheck, we must have a copy of your
timecard no later than 10 AM on Monday. If it is not in by this time, your paycheck may be
delayed until the following week.
For your convenience, you can obtain a copy of our timecard at www.staffingsolutionsllc.com.
Go to “Career Opportunities”. On the left, click “Required Paperwork Downloads”, then “Timesheet/Timecard”.
After completing the timecard, make a copy for your supervisor and yourself, then submit as outlined above.
If you have any problems with your paycheck, please contact Susan in our Accounting Department at
Susan and your recruiter need to know of any changes in your address or telephone number. Please fill
out a new W‐4 if you require any changes of your withholding status and allow one week for the
changes to become effective.
HOW DO YOU WANT YOUR PAY CHECK DELIVERED TO YOU
Please indicate below if you want your pay check mailed to you, if you would like to pick it up yourself or if
you want a direct deposit to your savings or checking account. We mail checks or earnings statements on
Thursday. We cannot release your paycheck to anyone other than yourself without your written permission
and telephone call.
Name: ( )
Please Print Telephone
City & Zip:
PICK-UP FRIDAY - After 12:00 Noon & Before 4:30 PM
DIRECT DEPOSIT – Available only if your assignment is a week or longer.
To enroll in Direct Deposit, fill out this form attach a voided check for the checking account (not a deposit
slip) in which you want your pay deposited and return it to Staffing Solutions, LLC. If depositing to a
savings account, ask your bank to give you the Routing Transit Number for your account. It isn't always the
same as the number on a savings deposit slip. This will help ensure that you are paid correctly.
Important! Please read and sign before completing and submitting.
I hereby authorize Staffing Solutions, LLC (hereinafter "Company") to deposit any amounts owed me by
initiating credit entries to my accounts at the financial institution (hereinafter "Bank") indicated on this form.
Further, I authorize Bank to accept and to credit any credit entries indicated by Company to my accounts. In
the event that Company deposits funds erroneously into my account, I authorize Company to debit my
account for an amount not to exceed the original amount of the erroneous credit.
This authorization is to remain in full force and effect until Company and Bank have received written notice
from me of its termination in such time and in such manner as to afford Company and Bank reasonable
opportunity to act on it.
Bank Name/City/State: __________________________________________________________________
Employee Name: (Print) ________________________________ Social Security #: ***-**-__________
ATTACH VOIDED CHECK TO THIS FORM – Do not tear off the bottom routing and account numbers.
CHANGE OF VITAL INFORMATION
Name ______________________________________ Social Security No: _______________________
New Name: _________________________________ Social Security No: _______________________
New Residence Address: ___________________________________________________________
New Mailing Address (if different): _____________________________________________________
New Phone No: _________________________ New Alternate Phone: _______________________
9 I pickup my check 9 Mail my checks to mailing address above
REQUEST FOR W-4 or W-5 CHANGES
If you have made any changes in marital status, exemptions or other matters that may effect your
withholding YOU MUST fill out and SIGN a new W-4 or W-5. ; NOTE: Exempt and over 9 dependants must be
reported to IRS.
I authorize the foregoing changes in my records. If checked, please send or give me a new 9 W-4 9 W-5.
_____________________________________________________ Date: ________________________
Office Use Only: Date entered and/or W-4,W-5 sent: ___________________
(copy to payroll, and make name, address or phone changes to their employee file)
REPORT ALL TIME TO NEAREST 1/4 HOUR
START STOP TOTAL LESS LUNCH DAILY TOTAL
EMPLOYEE / LAST NAME FIRST NAME
________ - _____ - _________ Is Assignment over? _____ Yes ____ No
Social Security Number
SAT ___________________________ _______________________
TOTAL STRAIGHT TIME __________________
WEEK ENDING ( Sunday) _____/_____/_____
TOTAL OVERTIME __________________
Staffing Solutions, LLC / K-Counsel® EMPLOYEE INSTRUCTIONS CLIENT’S AGREEMENT
610 SW Broadway, Suite 500
Portland, Oregon 97205 PLEASE FAX this to us upon signing by I have agreed to the terms and conditions of the
T: 503.295.9948 supervisor and mail or deliver to us by Monday Master Agreement previously received & the terms
F: 503.295.9977 of the following week. of service on the back of this time sheet.
CERTIFICATION I have verified the hours worked as reported on this
time record and state they were performed
Under penalty of perjury, I certify that I have satisfactorily.
actually worked the hours reported and that I have
worked no other hours. SUPERVISOR’S SIGNATURE
Date _____/_____/_____ Date _____/_____/_____
You agree that the terms following shall apply in addition to the terms of the Master Agreement (IF YOU DO NOT have a copy of the MASTER
AGREEMENT contact us immediately) to every transaction between us, Staffing Solutions, LLC and you (our Client):
1. You agree to pay on receipt of invoice the charges at the quoted rate for the hours worked as reported and verified on the time card. Any overtime as required
by law will be billed at 1 ½ times the quoted bill rate. If payment is not received within five (5) days of the invoice, you agree to pay an additional 1.5% per month on
the outstanding balance.
2. You agree to notify us immediately if there are any changes in the employee's job duties from those originally specified.
3. You will provide our employee with a suitable place to work. You agree to comply with all laws regulating employment practices and places of
4. Without our permission, you will not allow our employee to have access to any unattended premises, to handle cash, negotiable instruments, jewelry or other
valuables. You will not give our employee a credit card or allow our employee to charge with any of your suppliers. You will not give or loan our employee any
equipment not to be use exclusively on your premises, such as a laptop computer or cell phone.
5. We do not provide insurance for our employee driving any vehicle. You agree to be responsible for any liability or claims arising out of operating any
vehicle by our employee while working for you. We do not provide insurance for any damage or loss to your property while in our employee's care, custody or control.
You agree to assume such loss.
If driving or handling of cash, securities, negotiable instruments or other valuables are required, then you will have to agree to an indemnity and hold
6. You agree to pay us our regular full time placement fee or conversion fee as set forth in the Master Agreement if you do any of the following: a) you transfer
our temporary employee to the payroll of any other company, b) you allow our employee to work for you directly or through any other company within 180 days after
completion of any assignment through us, c) you allow our temporary employee to work for a subcontractor of yours within 180 days after completion of any
assignment through us, or d) you or any related company to you hires our temporary employee.
7. You agree the we are entitled to our attorney fees together with all expenses (including collection agency fees) if it becomes necessary to hire an attorney to
collect any sums due or to enforce any other provision of this agreement.
Modifications to this agreement must be in writing and approved by counsel for Staffing Solutions, LLC.