New Hire Applicant Information

Name *

First

Last

Date: *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone *

Cell Phone *

Email *

Social Security No: *

Date of Birth: *

CHECK ONE OF THE FOLLOWING: *

Journeyman Linemen
Apprentice Step
Groundman/Operator
Other Position

Are you a citizen of the United States? *

Yes
No

If no, are authorized to work in the U.S.? *

Yes
No

Are you a CDL class A/B driver? *

Yes
No

Are you a CDL driver? *

Yes
No

UNION AFFILIATION

Local Union: *

Union Phone

Card # *

This may not affect your employment ability with Essex Energy, LLC

Have you EVER been banned and/or informed you cannot work with any Utility Company/Companies: *

Yes
No

If YES, List the name of the Company/Companies. Name(s) *

Also list date/dates you were banned. Date(s) *

Military Service

Multiple Choice *

Yes
No

Branch: *

From: *

To: *

Rank at Discharge: *

Type of Discharge: *

If other than honorable, explain: *

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Signature: *

Date: *

EMPLOYEE EMERGENCY CONTACT FORM

Your Name: *

Your Department: *

Personal Contact Info:

Home Address: *

Address Line 1

City

State

Zip Code

Home Telephone # *

Cell # *

Emergency Contact Info:

(1) Name: *

Relationship: *

Address: *

Address Line 1

City

State

Zip Code

Home Telephone # *

Cell # *

Work Telephone # *

Employer: *

(2) Name: *

Relationship: *

Address: *

Address Line 1

City

State

Zip Code

Home Telephone # *

Cell # *

Work Telephone # *

Employer: *

Medical Contact Info:

Doctor Name: *

Phone # *

Dentist Name: *

Phone # *

Insurance (Medical): *

Policy# *

Checkbox *

I have voluntarily provided the above contact information and authorize Essex Energy, LLC and its representatives to contact any of the above on my behalf in the event of an emergency.

Signature *

Date: *

VEHICLE POLICY

As an authorized driver of a company vehicle, you have been given certain privileges. You assume the duty of obeying all motor vehicle laws, maintaining the vehicle properly at all times and, otherwise, following the policies and procedures outlined in the following.
Chief Executive Officer and Fleet Administrator: Takesha M. Essex

Vehicle Fleet Purpose

Company vehicles are provided to support business activities and are to be used only by qualified and authorized employees. They are not to be considered a part of an employee’s compensation and must not be used as an inducement for employment. In all cases, these vehicles are to be operated in strict compliance with motor vehicle laws of the jurisdiction in which they are driven and with the utmost regard for their care and cost-efficient use.

Company vehicles may not be used for business activities of other companies.
Company vehicles may not be driven to Canada or Mexico unless specified.

Driver Licensing

Company drivers and anyone authorized to drive the company vehicles must have a valid driver’s license issued in the state of residence for the class of the vehicle being operated and must be able to drive a vehicle. Obtaining a driver’s license is a personal expense.

Driver Qualifications

Driver qualifications are as follows:

Authorized employee of company, employees, spouse or significant other.
Must be at least 21 years of age.
Have at least one year of experience in the class of vehicle operated.
Must meet licensing requirements.
Will not qualify for a company vehicle if, during the last 36 months, the driver had any of the following experiences:

Been convicted of a felony.
Been convicted of sale, handling or use of drugs.
Been convicted of an alcohol- or drug-related offense while driving.
Had driver’s license suspended or revoked.
Been convicted of three or more speeding violations or one or more other serious violations.
Been involved in three or more chargeable accidents.

Review of Motor Vehicle Record

State Motor Vehicle Records (MVRs) will be used as the source for verifying driver history. MVRs will be obtained and reviewed at least annually on the employee, employee spouse, or significant other. (The insurance company requires that we provide them with the driver’s license number and date of birth for anyone who may drive a company vehicle.) Driving privileges may be withdrawn or suspended and/or the company vehicle removed from any authorized driver not meeting the above requirements. In addition, appropriate disciplinary action may be taken, up to and including termination of employment.

PLEASE READ, DATE, AND SIGN THE ATTACHED “EMPLOYEE AUTHORIZATION FOR MVR REVIEW”.

Personal Use

Company vehicles are provided for business purposes ONLY.
Rules Applying to Use of Company Vehicles:

Personal trailers, including boat and recreational vehicles, are NOT to be pulled.
Company vehicles are NOT to be driven while under the influence of alcohol or any controlled substance
Possession, transportation, or consumption of alcohol or illegal drugs by anyone in the vehicle is NOT allowed.
Driver and all passengers must wear available personal restraints (seatbelts).
Report any accident immediately to the police and your manager.

Any exceptions to these rules require to advance, written approval by the approved company manager or officer. Violation of these rules will result in disciplinary action from the removal of driving privileges to the termination of employment.

Maintenance

Liability

The company does not assume any liability for bodily injuries or property damage the employee may become personally obligated to pay arising out of an incident occurring in connection with the operation of company-owned vehicles while under the influence of a controlled substance both legal and illegal. In the event that an employee drives a company truck while under the influence of a controlled substance that impairs his or her ability to operate a vehicle, he/she will be held 100% responsible for damages both to the company vehicle and any other damages. Driving while under the influence of a controlled substance is automatic termination.

Traffic Violations

Fines for parking or moving violations, towing storage, or impoundment is the personal responsibility of the assigned operator. The company will not condone nor excuse ignorance of any motor vehicle violations that result in court summons being directed to itself as the owner of the vehicle. Each driver is required to report all moving violations to Takesha M. Essex– Fleet Manager within 24 hours. This requirement applies to violations involving the use of any vehicle (company, personal or other) while on company business. Failure to report violations will result in appropriate disciplinary action, including revoking driver privileges and possible termination of employment.

Cellular/mobile phones

Cellular/mobile phones should not be used while operating a vehicle. Using a cell phone while driving leads to an increased risk of having an accident through a lack of attention to driving. Inattention is the #1 cause of vehicle accidents in America. Inattention can also involve adjusting the radio, eating, smoking, daydreaming, talking to passengers, things outside the vehicle, and other distractions.

Researchers at the University of Toronto found that the risk of having a traffic accident while using a cell phone is the same as that while driving drunk. In eleven countries and several US cities, it is illegal to use a cell phone while operating a vehicle. Regulation of the use of phones in vehicles has been the subject of more than one hundred bills in thirty-seven states.

Allow voice mail to handle your calls and return them at your safe convenience.
If you need to place or receive a call pull off the road to a safe location.
Ask a passenger to make or take the call.
Inform regular callers of your driving schedule, and when you will be available to talk.
Keep your hands on the wheel and your eyes and mind on the road while driving.

In the event of an accident:

Call the police on all accidents and obtain a copy of the police report.
Do not admit negligence or liability.
Do not attempt settlement, regardless of how minor.
Get the name, address, and phone number of the injured person and witnesses if possible.
Exchange vehicle identification, insurance company name, and policy numbers with the other driver.
Take a photograph of the scene of the accident if possible.
Complete the accident report in your vehicle.
Turn all information over to Takesha M. Essex– Fleet Manager within 24 hours.

Thefts In the event of the theft of a company vehicle, notify local police and Fleet Manager Takesha M. Essex immediately

Driver Responsibilities Each driver is responsible for the actual possession, care, and use of the company vehicle in their possession. Therefore, a driver’s responsibilities include, but are not limited to, the following:

Operation of the vehicle in a manner consistent with reasonable practices that avoid abuse, theft, neglect, or disrespect of the equipment.
Obey all traffic laws.
The use of seat belts and shoulder harnesses is mandatory for drivers and passengers.
Adhering to manufacturer’s recommendations regarding service, maintenance, and inspection. Vehicles should not be operated with any defect that would prevent safe operation.
Attention to and practice of safe driving techniques and adherence to current safety requirements.
Restricting the use of vehicles to authorized drivers, spouses, or significant others.
Reporting the occurrence of moving violations.

Failure to comply with any of these responsibilities will result in disciplinary action, up to and including termination of employment.

Preventable Accidents A preventable accident is defined as an accident involving a company vehicle – whether being used for company or personal use – or any vehicle while being used on company business that results in property damage and/or personal injury, and in which the driver in question failed to exercise every reasonable precaution to prevent the accident.

1. Safety Guidelines to Prevent Accidents

Do Not Follow too close
Do Not Drive too fast for conditions
Do Not Fail to observe clearances
Do Not Fail to obey signs
Do Not Make Improper turns
Do Not Park improperly
Do Not Pass improperly
Do Not Fail to yield
Do Not Fail to obey traffic signals or directions
Do Not Exceed the posted speed limit
Do Not Drive While Intoxicated (DWI) or Drive Under the Influence (DUI) or similar charges.

Checkboxes *

I have read and will abide by the conditions as stated in this document regarding the operation of any vehicle for company business.

Name (printed) *

Signature *

Today’s date *

EMPLOYEE AUTHORIZATION FOR MVR REVIEW

As a prospective employee or current employee, I understand a Motor Vehicle Abstract will be ordered and reviewed to assess minimum eligibility to determine driving privileges. As a driver of a company vehicle or my own vehicle on the company’s behalf, I understand that it is my responsibility to operate the vehicle in a safe manner and to drive defensively to prevent injuries and property damage. Drivers must have a valid driver’s license for the type of vehicle to be operated and keep the license (s) with them at all times while driving. All drivers must comply with all applicable regulations. I also understand that my employer will periodically review my Motor Vehicle Record to determine continued eligibility to drive a company vehicle or operate my own vehicle on the company’s behalf. In accordance with the Fair Credit Reporting Act, I have been informed that a Motor Vehicle Record will be periodically obtained on me for continued employment purposes. I acknowledge the receipt of the above disclosure and authorize my employer or its designated agent to obtain a Motor Vehicle Record Report. This authorization is valid as long as I am an employee or employee candidate and may only be rescinded in writing.

Checkboxes *

I have read and understood these conditions

Employee Name (Print): *

Driver’s License Number: *

Employee’s Signature Date *

DUES DEDUCTION AUTHORIZATION

I hereby authorize and direct Essex Energy, LLC to deduct from my pay an amount equal to the dues and initiation fees in the amounts fixed in accordance with the Bylaws of Local Union and will vary due to storm restoration locations and the Constitution of the International Brotherhood of Electrical Workers and to pay same to said Local Union in accordance with the terms of the bargaining agreement between the Employer and the Union.
This authorization is voluntarily made in order to pay my fair share of the Union’s cost of representing me for the purposes of collective bargaining, and this authorization is not conditioned on my present or future membership in the Union.
This authorization shall be irrevocable for a period of one year from the date hereof or until the termination date of said agreement, whichever occurs sooner, without regard to whether I am a member of the Union during that period, and I agree that this authorization shall be automatically renewed and irrevocable for successive periods of one year unless revoked by written notice to you and the Union within the ten (10) day period prior to the anniversary of this authorization. I understand that under current law the payments covered by this authorization are not deductible as charitable contributions for federal income tax purposes.

Name (printed) *

Signature *

Date: *

Dept:

Paychex

Direct Deposit Enrollment/Change Form*
Company Name and/or Client Number Essex Energy, LLC.

Employee/Worker Name *

Employee/Worker Number

Please Note:

Employee/Worker: Retain a copy of this form for your records. Return the original to your employer/company.
Employer/Company: Please retain a copy of this document for your records.

Add New *

Update existing account
Replace existing account

Last 4 digits of the existing account number *

Type of Account *

Checking
Savings

Account Holder's Name: *

Routing/Transit Number: *

Checking/Savings Account Number** *

Financial Institution ("Bank") Name: *

I wish to deposit (check one): *

% of Net
Specific Dollar Amount $ .00

Remainder of Net Pay

Add New *

Update existing account
Replace existing account

Last 4 digits of the existing account number *

Type of Account *

Checking
Savings

Account Holder's Name: *

Routing/Transit Number: *

Checking/Savings Account Number** *

Financial Institution ("Bank") Name: *

I wish to deposit (check one):

% of Net
Specific Dollar Amount $ .00

Remainder of Net Pay

Add New

Update existing account
Replace existing account

Last 4 digits of the existing account number

Type of Account

Checking
Savings

Account Holder's Name:

Routing/Transit Number:

Checking/Savings Account Number**

Financial Institution ("Bank") Name:

I wish to deposit (check one):

% of Net
Specific Dollar Amount $ .00

Remainder of Net Pay

CONFIRMATION STATEMENT

I authorize my employer/company to deposit my earrings into the bank account(s) specified above and. it necessary. to electronically debit my account to correct erroneous entries. I certify my account(s) allow these transactions. Furthermore. I certify that the above listed account number acaxately reflects my intended receiving account. I agree that direct deposit transactions I authorize comply with all applicable laws. My signature below indicates that tam agreeing that l am either the accountholder or have the authority of the accountholder to authorize my employer/company make direct deposits into the named account. I understand that this authorization wit remain in full force and effect until !notify Company in writing that I wish to revoke my authorization! understand that the Company requires at least 5 business days Prior notice to cancel this authorization

Employee/Worker Signature *

Date *

Checkboxes *

I confirm that the above named employee/worker has added or changed a bank account for direct deposit processed by Paychex, Inc. I have reviewed the information provided and it is accurate to the best of my knowledge. My signature below indicates that I have the authority to execute this document on behalf of the Client.

Employee's Withholding Certificate

Complete your W-4 so that your employer can withhold the correct federal income tax from your pay.
Give Form W-4 to your employer.
Your withholding is subject to review by the IRS.

General Instructions and Job Worksheet

Click here to download

Step 1:

Enter Personal Information

(a) *

First

Middle

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

(b) Social Security Number: *

Does your name match the name on your Social Security Card? If not, to ensure you get credit for your earnings. Contact SSA at 800-772-1213 or go to www.ssa.gov.

(c) *

Single or Married filling separately
Married filling jointly or Qualifying widow(er)
Head of Household

Head of Household (Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual)

Note:

Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can claim exemption from withholding, when to use the estimator at www.irs.gov/W4App, and privacy

Step 2: Multiple Jobs or Spouse Works

Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse also works. The correct amount of withholding depends on income earned from all of these jobs.

Do only one of the following *

Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3–4); or
Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding; or
If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld

TIP: To be accurate, submit a W-4 for all other jobs. If you (or your spouse) have self-employment income, including as an independent contractor, use the estimator.

Complete Steps 3–4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3–4(b) on the Form W-4 for the highest paying job.)

Step 3: Claim Dependents

If your total income will be $200,000 or less ($400,000 or less if married filing jointly):

Multiply the number of qualifying children under age 17 by $2,000 *

Multiply the number of other dependents by $500 *

Total amount *

$ 0.00

Step 4: (optional): Other Adjustments

Other income (not from jobs). If you want tax withheld for other income you expect this year that won’t have withholding, enter the amount of other income here. This may include interest, dividends, and retirement income

Deductions. (If you expect to claim deductions other than the standard deduction and want to reduced your with holding, use the Deductions Worksheet on page 3 and enter the result here)

Extra withholding. Enter any additional tax you want withheld each pay period

Step 5: Sign Here

Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.

Employee’s signature (This form is not valid unless you sign it.) *

Date: *

Employers Only

Employer’s name and address

Essex Energy, LLC
03 South Washington Ave. Suite 206 Mailbox #8
Saginaw, MI 48607

First date of employment *

Employer identification number (EIN)

18-1414818

MI-W4

EMPLOYEE’S MICHIGAN WITHHOLDING EXEMPTION CERTIFICATE STATE OF MICHIGAN – DEPARTMENT OF TREASURY

This certificate is for Michigan income tax withholding purposes only. Read instructions on page 2 before completing this form.

INSTRUCTIONS TO EMPLOYEE’S MICHIGAN WITHHOLDING EXEMPTION CERTIFICATE (Form MI-W4)

Click here to download

1. Full Social Security Number *

2. Date of Birth *

3. Name (First, Middle Initial, Last) *

First

Middle

Last

4. Driver’s License Number or State ID *

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

Address Line 1

Address Line 2

City

State

Zip Code

5. Are you a new employee? *

Yes
No

If Yes, enter date of hire *

6. Enter the number of personal and dependent exemptions (see instructions) *

7. Additional amount you want deducted from each pay (if employer agrees)

8. I claim exemption from withholding because (see instructions) *

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

8(a)(Optional) Explain: if select "Option B" (Wages are exempt from withholding.)

8(b)(Optional) Use if selected "Option C" Located in the following Renaissance Zone:

EMPLOYEE:

If you fail or refuse to file this form, your employer must withhold Michigan income tax from your wages without allowance for any exemptions. Keep a copy of this form for your records. See additional instructions on page 2.
Under penalty of perjury, I certify that the number of withholding exemptions claimed on this certificate does not exceed the number I am allowed to claim. If claiming exemption from withholding, I certify that I do not anticipate a Michigan income tax liability this year

9. Employee’s Signature *

Date *

EMPLOYER: Complete the below section.

10. Employer’s Name

Essex Energy, LLC

11. Federal Employer Identification Number

86-1414818

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

203 Suite 206 Mailbox #8 South Washington Ave.

City or Town

Saginaw

State

MI

ZIP Code

48607

Name of Contact Person

Takesha M. Essex

Contact Phone Number

(989) 737-6122

INSTRUCTIONS TO EMPLOYER:

Keep a copy of this certificate with your records. All new hires must be reported to the State of Michigan. See www.mi-newhire.com for information.
In addition, a copy of this form must be sent to the Michigan Department of Treasury if the employee claims 10 or more exemptions or claims they are exempt from withholding. Send a copy to:

Michigan Department of Treasury
Tax Technical Section
P.O. Box 30477
Lansing, MI 48909

State of Michigan New Hire Reporting Form

Federal law requires public (State and local) and private employers to report all newly hired or rehired employees who are working
in Michigan to the State of Michigan.1 This form is recommended for use by all employers who do not report electronically.

A newly hired employee is an individual not previously employed by you, and a rehired employee is an individual who was previously employed by you but separated from employment for at least 60 consecutive days.

Reports must be submitted within 20 days of hire date (i.e., the date services are first performed for pay).

This form may be photocopied as necessary. Many employers preprint employer information on the form and have the employee complete the necessary information during the hiring process

When reporting new hires with special exemptions, please use the MI-W4 form.

Online and other electronic reporting options are available at:
www.mi-newhire.com/

Employers who report electronically and have employees working in two or more states may register as a multi-state employer and designate a single state to which new hire reports will be transmitted. Information regarding multi-state registration is available online at http://www.acf.hhs.gov/programs/cse/newhire/employer/private/newhire.htm#multi or call (410) 277-9470.

Reports will not be processed if mandatory information is missing. Such reports willl be rejected and you must correct and resubmit them.

For optimum accuracy, please print neatly in all capital letters and avoid contact with the edge of the box. See sample below.

ABC123

EMPLOYEE Information (Mandatory)

Social Security Number: *

First Name: Middle Initial: Last Name: *

First

Middle

Last

Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Hire Date: *

Date of Birth

Driver’s License No: *

EMPLOYER Information (Mandatory)

Federal Employer Identification Number (FEIN):

86-1414818

Employer Name:

Essex Energy, LLC

Address:

203 S. Washington Ave. STE. 260 #8 Saginaw MI 48707 1208

Employer Information

Contact Name: Takesha M. Essex
Contact Phone: 989 737 6122
Contact Email: [email protected]

Employment Eligibility Verification

Department of Homeland Security
U.S. Citizenship and Immigration Services

► START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination

Section 1. Employee Information and Attestation

(Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)

Last Name (Family Name) *

First Name (Given Name) *

Middle Initial

Other Last Names Used (if any)

Address (Street Number and Name) *

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth (mm/dd/yyyy) *

U.S. Social Security Number *

Employee's E-mail Address *

Employee's Telephone Number *

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

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

1. A citizen of the United States
2. A noncitizen national of the United States (See instructions)
3. A lawful permanent resident
4. An alien authorized to work until

(Optional) if select "Option 3"(Alien Registration Number/USCIS Number):

(Optional) if select "Option 4"(expiration date, if applicable, mm/dd/yyyy):

Some aliens may write "N/A" in the expiration date field. (See instructions)

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9:
An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

1. Alien Registration Number/USCIS Number:

OR

2. Form I-94 Admission Number:

OR

3. Foreign Passport Number:

OR

Country of Issuance:

Signature of Employee *

Today's Date (mm/dd/yyyy) *

Preparer and/or Translator Certification (check one):

I did not use a preparer or translator.
A preparer(s) and/or translator(s) assisted the employee in completing Section 1.

(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.

Signature of Preparer or Translator

Today's Date (mm/dd/yyyy)

Last Name (Family Name)

First Name (Given Name)

Address (Street Number and Name)

Address Line 1

Address Line 2

City

State

Zip Code

989 737 6122

[email protected]

San Andreas, USA

New Hire Applicant Information

UNION AFFILIATION

This may not affect your employment ability with Essex Energy, LLC

Military Service

Disclaimer and Signature

EMPLOYEE EMERGENCY CONTACT FORM

Personal Contact Info:

Emergency Contact Info:

Medical Contact Info:

VEHICLE POLICY

EMPLOYEE AUTHORIZATION FOR MVR REVIEW

DUES DEDUCTION AUTHORIZATION

Paychex

Please Note:

CONFIRMATION STATEMENT

Employee's Withholding Certificate

General Instructions and Job Worksheet

Step 1:

Note:

Step 2: Multiple Jobs or Spouse Works

TIP: To be accurate, submit a W-4 for all other jobs. If you (or your spouse) have self-employment income, including as an independent contractor, use the estimator.

Step 3: Claim Dependents

Step 4: (optional): Other Adjustments

Step 5: Sign Here

Employers Only

Employer’s name and address

Employer identification number (EIN)

MI-W4

EMPLOYEE’S MICHIGAN WITHHOLDING EXEMPTION CERTIFICATE STATE OF MICHIGAN – DEPARTMENT OF TREASURY

INSTRUCTIONS TO EMPLOYEE’S MICHIGAN WITHHOLDING EXEMPTION CERTIFICATE (Form MI-W4)

EMPLOYEE:

EMPLOYER: Complete the below section.

10. Employer’s Name

11. Federal Employer Identification Number

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

City or Town

State

ZIP Code

Name of Contact Person

Contact Phone Number

INSTRUCTIONS TO EMPLOYER:

State of Michigan New Hire Reporting Form

EMPLOYEE Information (Mandatory)

EMPLOYER Information (Mandatory)

Federal Employer Identification Number (FEIN):

Employer Name:

Address:

Employer Information

Employment Eligibility Verification

► START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form.

Section 1. Employee Information and Attestation

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

(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)

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