Please reference the last three places where you have worked.


I hereby affirm all the information provided in this application is accurate and true I understand that any falsification or willful omission is grounds for ceasing a!! placement activity and/or immediate dismissaL In signing this application, I authorize Action Staffing Group to conduct reference and background checks, and to obtain information relating to my current and prior employmen/work history and educational credentials. l further authorize Action Staffing Group to share with its clients or customers any of the information contained on or obtained in connection with this application. I understand that some clients will require extensive background, criminal and credit checks as well as drug testing. In consideration of my hiring and employment by Action Staffing Group, I agree not to accept employment, directly or indirectly, whether full-time or part-time, with any client of Action Staffing Group to whom I am assigned and for a period of one hundred eighty (180) days following completion of any assignment with the client and not to accept assignment to work for such client either on its premises or as the employee of a third party except with the prior written consent of Action Staffing Group, I hereby agree to confirm you if l have been offered permanent employment with any companies that I have worked through this temporary agency.

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I hereby agree that Action Staffing Group may advance on my behalf the cost of transportation of each week to my jobsite
and that I shall repay this loan at the end of the same week by having Action Staffing Group deduct this cost of transportation without any interest accruing thereon directly fom my paycheck.

I also understand that using this transportation is voluntaiy and not a prerequisite of employment and that I will only be responsible for paying each week the amounts actually advance on my behalf for transportation, and nothing further.
Furthermore, I acknowledge that it is my responsibility to travel to my temporary worksite so that I arrive at work at the proper start time for my assignment. It is up to me to decide whether to travel to work on my own or with the assistance of independent drivers.

This document shall constitute the loan and repayment agreement between Action Staffing Group and me with respect to such transpmtation related advances.

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Loan and Repayment Agreement for Clothing and Safety Equipment

Pursuant to the provisions of N.J.S.A. 34:1-4.4(6) and H.J.A.C. 12:56-17.1 Action Staffing Group with the express consent of the temporary employee, hereby agrees to allow Action Staffing Group to lease to the temporary employee the dark shirt, dark work pants and will Launder and dry clean same which do not have any Action Staffing logo or language on the dark shirt and pants and the same are suitable for street wear. With regard to the gloves, safety vests and steel toed work boots same are safety equipment for the temporary employee and with the express consent of the temporary employee Action Staffing Group will purchase and/or lease the safety equipment for the temporary employee. Likewise, where Action Staffing Group has been retained to provide temporary employees where the client of Action Staffing Group requires safety equipment consisting of safety vests, steel toed work boots and gloves.

The temporary employee expressly warrants, represents and understands that the dark shirt, dark work pants, steel toed work boots when required and/or gloves when required by the clients of Action Staffing Group must be worn at each location of the clients of Action Staffing Group while they are working at their assigned location. The failure to do so when required by the clients of Action Staffing and/or Action Staffing Group shall be grounds for immediate termination.

The cost for the leasing, laundering and/or dry cleaning of the dark shirt, dark work pants, steel toed work boots and/or gloves with the express consent of the temporary employee shall be deducted by Action Staffing Group from the temporary employee’s paycheck provided the deduction does not reduce the employee’s paycheck below minimum wage. In the event that the cost to Action Staffing Group for the leasing, laundering, and or dry cleaning reduces the minimum wage for the next pay check the temporary employee, then these costs will be deducted from each succeeding paycheck to the temporary employee until Action Staffing Group has been full reimbursed.


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Disclosure And Authorization For Consumer Reports


In connection with my application for employment (including contract or volunteer services) or application to rent a dwelling with Action Staffing Group , at 1145 Elizabeth Ave. Elizabeth, NJ 07201

I understand consumer reports will be requested by you (“Company”). These reports may include, as allowed by law, the following types of information, as applicable: names and dates of previous employers, reason for termination of employment, work experience, reasons for termination of tenancy, former landlords, education, accidents, licensure, credit, etc. I further understand that such reports may contain public record information such as, but not limited to: my driving record, judgments, bankruptcy proceedings, evictions, criminal records, etc., from federal, state, and other agencies that maintain such records.

In addition, investigative consumer reports (gathered from personal interviews, as applicable, with former employers or landlords, past or current neighbors and associates of mine, etc.) to gather information regarding my work or tenant performance, character, general reputation and personal characteristics, and mode of living (lifestyle) may be obtained.


I hereby authorize procurement of consumer report(s) and investigative consumer report(s) by Company. If hired (or contracted), this authorization shall remain on file and shall serve as ongoing authorization for Company to procure such reports at any time during my employment, contract, or volunteer period. I authorize without reservation, any person, business or agency contacted by the consumer reporting agency to furnish the above­mentioned information.

This authorization is conditioned upon the following representations of my rights:

I understand that I have the right to make a request to the consumer reporting agency: Background Screeners of America (“Agency”), 18344 Oxnard Street, Ste. 101, Tarzan a, CA 91356, telephone number 866-570-4949, upon proper identification, to obtain copies of any reports furnished to Company by the Agency and to request the nature and substance of all information in its files on me at the time of my request, including the sources of information, and the Agency, on Company’s behalf, will provide a complete and accurate disclosure of the nature and scope of the investigation covered by any investigative consumer report(s). The Agency will also disclose the recipients of any such reports on me which the Agency has previously furnished within the two year period for employment requests, and one year for other purposes preceding my request (California three years). I hereby consent to Company obtaining the above information from the Agency. I understand that I can dispute, at any time, any information that is inaccurate in any type of report with the Agency. I may view the Agency’s privacy policy at their website:

I understand that if the Company is located in California, Minnesota or Oklahoma, that I have the right to request a copy of any report Company receives on me at the time the report is provided to Company. By checking the following box, I request a copy of all such reports be sent to me.

California Applicants:

As a California applicant, I understand that I have the right under Section 1786.22 of the California Civil Code to contact the Agency during reasonable hours (9:00 a.m. to 5:00 p.m. (PTZ) Monday through Friday) to obtain all information in Agency’s file for my review. I may obtain such information as follows: 1) In person at the Agency’s offices, which address is listed above. I can have someone accompany me to the Agency’s offices. Agency may require this third party to present reasonable identification. I may be required at the time of such visit to sign an authorization for the Agency to disclose to or discuss Agency’s information with this third party; 2) By certified mail, if I have previously provided identification in a written request that my file be sent to me or to a third party identified by me; 3) By telephone, if I have previously provided proper identification in writing to Agency; and 4) Agency has trained personnel to explain any information in my file to me and if the file contains any information that is coded, such will be explained to me.

New York Applicants:

I understand that if I am applying for employment in New York, that I have the right to receive a copy of Article 23-A of the New York Correction Law _____ (initial if this applies).

Washington Applicants:

I understand that if the report is provided to an employer in the State of Washington, that I can contact the following office for more information regarding my rights under Washington state law in regard to these reports: State of Washington Attorney General, Consumer Protection Division, 800 5th Ave, Ste. 2000, Seattle, Washington 98104-3188, (206) 464-7744.

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New Hire EE0-1 Data Sheet

Please complete this New Hire EE0-1 Data Sheet. It will supply us with information we need for federal reporting obligations. Please be advised that this information will be used and kept confidential, in accordance with applicable laws and regulations. This information will not be used as the basis for any adverse employment decision.

EEO-1 Self-Identification

We are subject to certain government recordkeeping and reporting requirements for the administration of civil rights laws and regulations. To comply with these laws, we invite you to voluntarily self-identify your race or ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and separate from personnel files. It may only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those requiring information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual.

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Many our positions will include physical labor, such as handling a hand truck, up and down stairs, which requires 2 hands, jumping up and down on and off trucks, lifting, stacking, carrying heavy boxes, bending, kneeling and squatting on a normal basis. ANY FALSE STATEMENT WILL BE CAUSE FOR DISCIPLINARY ACTION INCLUDING IMMEDIATE TERMINATION.



Please complete all questions, and sign and date the form.

*If you checked yes please provide a copy of your SSI documentation.

4. Have you received any type of vocational l’ehabilitation services within the past two years?
lf yes, please indicate which type of agency you worked with and provide their location information below:

*if yes, please indicate which type of agency you worked with and provide their location information below:

*If you checked yes please provide a copy of your active Individual Work Plan and ticket to Work documentation.


Additional Tax Credits

*if you checked yes please provide a copy of your CDIB card.


Under penalties of perjury, I declare the information above to be true and accurate to the best of my knowledge, and I hereby authorize any agency, organization, or individuals to supply such verification or information that may be needed to determine tax credit eligibility to my employer, employer representative (Associated Consultanls, Inc. dba Retrotax), or the Department of Labor.

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Pre-Screening Notice and Certification Request for the Work Opportunity Credit

  • I am a member of a family that has received assistance from Temporary Assistance for Needy Families (TANF) for any 9 months during the past 18 months.
  • I am a veteran and a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (food stamps) for at least a 3-month period during the past 15 months.
  • I was referred here by a rehabilitation agency approved by the state, an employment network under the Ticket to Work program, or the Department of Veterans Affairs.
  • I am at least age 18 but not age 40 or older and I am a member of a family that
    d. Received SNAP benefits (food stamps) for the past 6 months; or
    b. Received SNAP benefits (food stamps) for at least 3 of the past 5 months, but is no longer eligible to receive them.
  • During the past year, I was convicted of a felony or released from prison for a felony.
  • I received supplemental security income (SSI) benefits for any month ending during the past 60 days.
  • I am a veteran and I was unemployed for a period or periods totaling at least 4 weeks but less than 6 months during the past year.
  • Received TANF payments for at least the past 18 months; or
  • Received TANF payments for any 18 months beginning after August 5, 1997, and the earliest 18-month period beginning after August 5, 1997, ended during the past 2 years; or
  • Stopped being eligible for TANF payments during the past 2 years because federal or state law limited the maximum time those payments could be made.
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Privacy Act and Paperwork Reduction Act Notice

Section references are to the Internal Revenue Code.

Section 51(d)(13) permits a prospective employer to request the applicant to complete this form and give it to the prospective employer. The information will be used by the employer to complete the employer’s federal tax return. Completion of this form is voluntary and may assist members of targeted groups in securing employment. Routine uses of this form include giving it to the state workforce agency (SWA), which will contact appropriate sources to confirm that the applicant is a member of a targeted group. This form may also be given to the Internal Revenue Service for the administration of the Internal Revenue laws, to the Department of, Justice for civil and criminal litigation, to the Department of Labor for oversight of the certifications performed by the SWA, and to cities, states, and the District of Columbia for use in administering their tax laws. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.
You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid 0MB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by section 6103.

The time needed to complete and file this form will vary depending on individual circumstances. The estimated average time is:

Recordkeeping . . . . . . . 6 hr., 27 min.
Learning about the law or the form . . . . . . . 24 min.
Preparing and sending this form to the SWA . . . . . . . 31 min.

If you have comments concerning the accuracy of these time estimates or suggestions for making this form simpler, we would be happy to hear from you. You can send us comments from Click on “More Information” and then on “Give us feedback.” Or you can send your comments to:

Internal Revenue Service
Tax Forms and Publications
1111 Constitution Ave. NW, IR-6526 Washington, DC 20224

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

Form W-4


Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes.

Exemption from withholding.

If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2017 expires February. 15, 2018. See Pub. 505, Tax Withholding and Estimated Tax.


If another person can claim you as a dependent on his or her tax return, you can’t claim exemption from withholding if your total income exceeds $1050 and includes more than $350 of unearned income (for example, interest and dividends).


An employee may be able to claim exemption from withholding even if the employee is a dependent, if the employee:

  • is age 65 or older,
  • Is blind or
  • Will claim adjustments to income; tax credits; or itemized deductions on his or her tax return. The exceptions don’t apply to supplement wages greater than $1,000,000

Basic Instructions.

If you aren’t exempt, complete the Personal Allowances Worksheet below. The worksheets on page 8 further adjust your withholding allowances based on itemized deductions, certain credits, adjustments to income, or two-earners/multiple jobs situations.

Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances you claimed and may not be a fiat amount or percentage wages.

Head of Household.

Generally, you can claim head of household filing status on your tax return only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See Pub, 501, Exemptions, Standard Deduction, and Filing Information, for information.

Tax credits.

You can take projected tax credits into account in figuring your allowable number of withholding allowances. Credits for a child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below. See Pub, 505 for information on converting your other credits into withholding allowances.

Nonwage Income.

If you have a large amount of nonwage income, such as interest or dividends consider making estimated tax payments using Form 1040-ES. Estimated Tax for Individuals. Otherwise, you may owe additional tax, if you have pension or annuity income. see Pub 505 to find out if you should adjust your withholding on Form W-4 or W-4P.

Two earners or multiple jobs.

If you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim o all jobs using worksheets from only one Form W-4 for the highest paying job and zero allowances are claimed on the others. See. Pub, 505 for details.

Nonresident alien.

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

Check your withholding.

After your Form W-4 takes effect, use Pub, 505 to see how the amount you are having withheld compares to your projected total tax for 2017. See, Pub, 505 especially if your earnings exceed $130000 (Single) or $180000 (Married)

Future developments.

Information about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted at

Employment Eligibility Verification

U.S Citizenship and Immigration Services
USCIS Form I-9
OMB No, 1615-0047
Expires 10/31/2022

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.

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 Attention

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.

Some aliens may write "N/A" in the expiration date field. (See instructions)
An Alien Registration Number/USCIS Number or Form I-94 Admission Number or Foreign Passport Number.
Do Not Write In This Space
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(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)
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Today's Date

Acknowledgment of Receipt of Gender Equity Notification

I received a copy of the gender equity notification on the date listed below. I have read it and I understand it.

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Action Staffing Acknowledgement Form

I, the undersigned, received a copy, read, understand and have been provided the opportunity to ask questions of each document and policy listed below. I also confirm that everything in the employment application was explained to me and I understand what I signed for. I understand that if I do not abide by the below policies, rules, and regulations, I am subject to disciplinary action, which may include my termination.

  • Action Staffing Rules & Regulations
  • Proper Work Attire
  • Action Staffing General Safety Rules
  • ASG Injury Reporting Process
  • Workers’ Compensation Philosophy
  • Substance Abuse and Drug Testing Policy
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