Action Staffing Group Commercial Drivers

SECTION 1: PERSONAL INFORMATION

SECTION 2: GENERAL INFORMATION

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 all 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 employment/work history and educational credentials. I 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 assigmnent 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 I have been offered permanent employment with any companies that I have worked through this temporary agency.

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Action Staffing Group does not discriminate in terms and conditions of employment on the basis of age, race, religion, gender, national origin, disability, veteran status, or any other basis that is prohibited by applicable law

COMMERCIAL DRIVER APPLICATION

FILL IN ALL BLANKS & PROVIDE ALL INFORMATION REQUESTED--PRINT OR TYPE

If your above address is less than 3 years continue listing them below to cover the previous 3-year period:


Driver's License Information: all licenses held, last 3 years:

Experience:

All Accidents, last 3 years: (If none, write NONE)

List all Traffic Violations Convictions, last 3 years: (If none, write NONE)

Employment History, last 10 years



Personal and Professional References

For driver applicants of commercial motor vehicles that require a Commercial Driver License (CDL) the applicant must disclose their controlled substance and alcohol status per the requirements of 49 CFR parts 40.25(j).

As a prospective driver employee, you have the right to review information provided by previous employers. You have the Right to have errors in the information corrected by the previous employer(s) and for that previous employer(s) to re-send the corrected infonnation to the prospective employer; the right to have a rebuttal statement attached to the alleged erroneous infonnation, if the previous employer and the driver cannot agree on the accuracy of the infonnation. Driver employees who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employer provided investigative information, must submit a written request to the prospective employer, which may be done at any time, including when applying or as late as thirty (30) days after being employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested infonnation from the previous employer(s), then the five (5) business day deadlines will begin when the prospective employer receives the requested safety perfonnance history infonnation. If the driver has not arranged to pick up or receive the requested records within thirty (30) days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived their request to review the records.

Certification

“I certify that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.”

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SIGNIFICANT DATES:

COMMERCIAL VEHICLE DRIVER APPLICANT Controlled Substance and Alcohol Questionnaire Pursuant to 49 CFR part 40.25G)

If YES—- Documentation MUST BE PROVIDED before any safety-sensitive transportation function is performed

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ANNUAL 2019 MOTOR VEHICLE DRIVER'S CERTIFICATION OF VIOLATIONS

certify that the following is a true and complete list of traffic violations (other than parking Violations) for which I have been convicted or forfeited bond or collateral during the past 12 months.

If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation required to be listed during the past 12 months.

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EMPLOYER VERIFICATION

SECTION 1: PREVIOUS EMPLOYEE INFORMATION & RELEASE

I hereby authorize ACTION STAFFING GROUP to release the following requested information for the purpose of investigation for qualifying me to drive a commercial motor vehicle as required by the U.S. Department of Transportation & Federal Motor Carrier Safety Regulations Parts 382,391,392 & 49 CFR Parts 40. You are hereby released from any and all liability that may result from furnishing such information. Your quick response to the request will be greatly appreciated.

SECTION 2: PREVIOUS EMPLOYEE WORK HISTORY

SECTION 3: NOTE REGULATIONS OF THE DEPT. OF TRANSPORTATION (49 CFR PART 40)

RULES AND REGULATIONS FOR ALL CDL DRIVES

Welcome to Action Staffing Group. We are pleased that you have selected our agency to help you look for a job assignment and hope that this opportunity leads to full-time employment for you. In order to increase your chances for success on the job, we require that you follow our rules and regulations and sign that you acknowledge receipt of such rules.

1. JOB ASSIGNMENT. Once you have accepted a job assignment you are expected to show up for work every day on time. Plan to be at the job site 5 minutes early every day to make a good impression. Be sure to review directions on getting to the work location the day before. Lateness may be grounds for disciplinary action, up to an including dismissal.

2. NEVER WALK OFF THE JOB FOR ANY REASON!!! If you encounter a problem, call our office as soon as possible to discuss the matter with our operations department. We will be happy to assist you. If you do walk off any assignment, it may be grounds for disciplinary action, up to and including dismissal. If you encounter a problem and are unable to go to work, you must notify us at least two hours before so that we can arrange coverage for you.

3. TIME AND ATTENDANCE. You must arrive to work on time. A NO CALL/NO SHOW may be grounds for disciplinary action, up to and including dismissal. If you are released from an assignment, you must notify your dispatch manager immediately. If you are not able to notify your dispatch manager, you must report to the office the next day. Failure to report to your manager is considered job abandonment and it may be grounds for dismissal.

4. DRESS CODE. Always dress for success on the job. This means the following: wear work boots (no sneakers), comfortable warn work clothes (appropriate fitting pants), and the proper uniform (if given for the site location). Work gloves are always a good idea. In the office, proper business attire at all times unless otherwise instructed. Dress codes of individual assignments should be followed as requested. Please exercise proper hygiene at all times when coming to work (well-groomed, clean clothes, and proper presentation).

5. TIMESHEETS and DRIVER SIGN-IN SHEETS ARE YOUR RESPONSIBILITY! Make sure you sign the ACTION DRIVERS SIGN IN SHEET/LOG Book and the route information, such as route number and route miles Be sure to track your work miles every day. Confirm that the timesheets are accurate in order to process them on time. (A forged signature on a timesheet will result in immediate termination).

6. PAYCHECKS. There is always a one-week delay on paychecks. This means if you work this week anytime from Monday through Sunday, you will be paid for that week the following Friday. Please make note of this and ask questions if you do not understand this procedure. Weekly paychecks are generally distributed on Fridays from 5 p.m. in our office. If you have any questions regarding your paycheck, please contact your office manager.

7. PAY RATES. Never discuss pay rates with the assigned company, assigned company’s employees or any other employee of Action Staffing Group. Address any pay rate questions or concerns with Action Staffing Group. We will be happy to assist you with your concerns.

8. Anytime that you are injured on the job, report your injury immediately to the Patty Curty to 908-242-1042. An additional form in this package outlines the work injury procedure that you must adhere to; failure to do so will lead to a delay in processing your claim.

9. Cell phones and other electronic devices (such as pagers, iPods, etc.) are not permitted to be used while on assignment. Use of any unauthorized devices while working may be grounds for disciplinary action, up to and including dismissal.
10TI EMPLOYMENT AT WILL. Understand that any assignment you are given is a temporary job and that employment is at will. Assignments can be ended at any time for any reason. It can be ended for cause if I fail to follow the directions of my group leader, supervisor or manager.

10. EMPLOYMENT AT WILL. Understand that any assignment you are given is a temporary job and that employment is at will. Assignments can be ended at any time for any reason. It can be ended for cause if I fail to follow the directions of my group leader, supervisor or manager.

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WORK INJURY PROCEDURES FOR ACTION STAFFING CDL DRIVERS

1. If you are injured at work, you must stop what you are doing and notify Action Staffing Group to 908-469-7251 or to your supervisor immediately to (Patty Cmiy 908-242-1042) (Jessica Vaquero 908-296-1792) as soon as possible for instructions.

2. After you have received the instructions from the Action Staffing Group representative, the next steps may include the following:

  • a. Receive the closest medical facility location for both emergency and non-emergency incidents.
  • b. Seek first aid and/or medical attention if required.

3. If you have seeker emergency medical attention, all documentation must be brought to the Action Staffing Group office within 24 hours of services provided by all medical facilities. Inform the medical facility that this is a work-related injury and provide the Action Staffing Group office information: Action Staffing Group, 16 Winfield Scott Plaza, Elizabeth, NJ 07201.

4. You MUST fill out an incident report with your immediate supervisor at the Action Staffing Group office within 24 hours of the injury so that we may submit it to the insurance carrier.

5. After the first visit, continuing visits must be approved by a representative at Action Staffing Group or the insurance carrier. This will ensure that you get the proper approval and necessary treatment.

6. After all visits, all documentation must be provided to an Action Staffing Group representative within 24 hours of services provided. This documentation will be passed on to the insurance carrier.

These steps are established to ensure you are within compliance with company procedures for work-related injuries. Failure to follow these procedures is non-compliant and may lead to a delay in services provided by Action Staffing Group, medical providers, and the insurance carrier.
You are responsible to communicate with management effectively at all times regarding any changes in your condition, and all related medical services provided due to the nature of the work-related injury. Failure to do so may leave you responsible for unapproved medical services provided.

(Print Name) understand the WORK INJURY PROCEDURES FOR ACTION STAFFING GROUP EMPLOYEES listed above, I understand than I’m completely responsible to communicate and provide all necessary information to any immediate supervisor at Action Staffing Group with the guidelines above.

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ACTION STAFFING GROUP SUBSTANCE ABUSE AND DRUG TESTING POLICY

Action Staffing is committed to providing a safe, efficient, and productive work environment that is alcohol and drug-free for all employees. While all positions may have, some risk involved, there are certain “safety-sensitive” positions that carry with them a greater degree of risk for both the employee occupying such a position and others surrounding or within that employee’s work environment. An employee in a “safety-sensitive” position using or being under the influence of drugs or alcohol on the job may pose a very serious safety and health risk.

Action Staffing strictly prohibits the use, distribution, sale or possession of any illegal drugs on the premises of Action Staffing, or its clients, or in any other work-related environment. Using or being under the influence of drugs or alcohol on the job is strictly prohibited.

In order to maintain a safe and healthful work environment, job applicants for certain assignments and applicants and/or employees of safety-sensitive positions may be asked to submit to urinalysis or some alternative form of testing to determine the illicit or illegal use of drugs and alcohol. While Action Staffing reserves the right to test randomly, periodically, or upon reasonable suspicion, a test will be required of any employee, regardless of the nature of the position, involved in a serious incident or accident that is alleged or deemed to arise out of and in the course of employment, on or off Action Staffing’s or its clients’ premises.

Refusal to submit to drug testing may result in disciplinary action and adverse consequences, up to and including termination of employment and potential loss of other benefits. Upon a positive test result, Action Staffing reserves the right to proceed in any manner it may choose which could include mandatory counseling prior to any future assignments, refusal to assign (to any or all clients), suspension or termination. CDL operators failed drug test will result in immediate termination. In addition, violations of this policy may have legal consequences.

A copy of this Substance Abuse and Drug Testing Policy will be provided to you. You will be asked to sign an acknowledgment form indicating you have received a copy of the policy. You are expected to have read the policy. Any questions concerning the policy or the procedure for administering it may be directed to an Action Staffing Manager.

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RESTRICTION QUESTIONNAIRE

Many of our positions will include physical labor, such as handling a hand truck, up and downstairs, 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.

CDL DRIVER TICKETS VIOLATIONS

All CDL Drivers will be responsible for any tickets the company will not cover such as speeding, red light, no turn violations or shortages in cash collects

hereby allow Action Staffing Group to deduct the necessary tickets violations amount from my paycheck that is part of my employment with Action Staffing Group for both temporary or permanent placement. We will notify you if any tickets come up.

CDL DRIVER APPLICANT DEDUCTION FORM

hereby allow Action Staffing Group to deduct the necessary internal job-related expenses from my paycheck that are part of my employment with Action Staffing Group for both temporary or permanent placement

hereby also allow Action Staffing Group to perform a criminal investigation and drug screen as directed by its clients for temporary and permanent employment. By signing this affidavit, I authorize these searches with full understanding that they may be shared with clients and employers for which I perform a service.

PLEASE BE AVISED WHETHER YOU PASS OR FAIL YOUR CRIMINAL BACKGROUND CHECK OR DRUG TEST YOU WILL BE RESPONSIBLE FOR THE COST.
Criminal Background Check (7 years), MVR check (3 years ) and DOT Drug Screen
2nd Week $40.25
3rd Week $40.25
Total $80.50

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Action Staffing Group 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 streetwear. 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 paycheck the temporary employee, then these costs will be deducted from each succeeding paycheck to the temporary employee until Action Staffing Group has been fully reimbursed.

THE PARTIES HAVE READ AND UNDERSTOOD THE FOREGOING TERMS AND CONDITIONS AND AGREE TO THEM AS OF THE DATE OF THE SIGNING OF THIS AGREEMENT. IF MORE THE ONE PARTY SIGNS BELOW, EACH AGREES TO BE LIABLE, JOINTLY AND SEVERALLY, FOR ALL OBLIGATIONS UNDER THIS AGREEMENT. THE PARTIES SHALL RECEIVE A FULLY EXECUTED DUPLICATE OF THIS AGREEMENT.

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New Hire EE0-1 Data Sheet

Please complete this New Hire EE0-1 Data Sheet. It will supply us with the 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.

EE0-1 Self-Identification

We are subject to certain governmental 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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THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS

IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

In connection with your application for employment with Action Staffing Group (“Prospective Employer”), Prospective. Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).

When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FM CSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report.

When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FM CSA; the name, address, and the toll-free telephone number of FMCSA; that the FM CSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FM CSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act.

Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to tl1e appropriate State for adjudication.

Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FM CSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.

The Prospective Employer cannot obtain background reports from FMCSA without your authorization.

AUTHORIZATION

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

I authorize. Action Staffing Group (“Prospective . Employer”) to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am authorizing the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee.

I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.

I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report.

I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.

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NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account-holders are required by federal law to obtain an Applicant’s written or electronic consent prior to accessing the Applicant’s PSP report. Further, account holders are required by FMCSA to use the language contained in this Disclosure and Authorization form to obtain an Applicant’s consent. The language must be used as a whole, exactly as provided. Further, the language on this form must exist as one stand-alone document. The language may NOT be included with other consent forms or any other language.

NOTICE: The prospective employment concept referenced in this form contemplates the definition of”employee” contained at 49 C.F.R. 383.5.

General Consent for Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol Clearinghouse

hereby provide consent to Action Staffing Group to conduct a limited query of the FMCSA Commercial Driver’s License Drug and Alcohol Clearinghouse (Clearinghouse) to determine whether drug or alcohol violation information about me exists in the Clearinghouse.

I understand that if the limited query conducted by Action Staffing Group indicates that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information to Action Staffing Group without first obtaining additional specific consent from me.

I further understand that if I refuse to provide consent for Action Staffing Group to conduct a limited query of the Clearinghouse, Action Staffing Group must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA’s drug and alcohol program regulations. However, I Understand that Action Staffing Group will be required to conduct a full query of the Clearinghouse within 24 hours after a limited query indicates that drug and alcohol information exist and that if I do not grant consent within the clearinghouse for that full query I will remove from performing safety-sensitive functions, including operating a commercial motor vehicle.

ACKNOWLEDGMENT AND AUTHORIZATION FOR BACKGROUND CHECK

I acknowledge receipt of the separate document entitled DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understood both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by Action Staffing Group at any time after receipt of this authorization and throughout my employment, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Background Screeners of America, 18344 Oxnard Street, Suite 101, Tarzana, CA 91356; Tel.# 1.877.251.5656; www.backgroundscrneersofamerica.com and/or Employer. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.

New York applicants only: Upon request, you will be informed whether or not a consumer report was requested by the Employer, and if such a report was requested, informed of the name and address of the consumer reporting agency that furnished the report. You have the right to inspect and receive a copy of any investigative consumer report requested by the Employer by contacting the consumer reporting agency identified above directly. By signing below, you acknowledge receipt of Article 23-A of the New York Correction Law.
New York City applicants only: You acknowledge and authorize the Employer to provide any notices required by federal, state or local law to you at the address(es) and/or email address(es) you provided to the Employer.

Washington State applicants only: You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

Minnesota and Oklahoma applicants only: Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Employer.

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Consent Form to Release Documents

I hereby give permission and consent to the Action Staffing Group to release the documents listed below to their Clients for the purpose of obtaining a driver position with said clients.

  • Motor Vehicle Report
  • Criminal Background
  • Drug Test Results
  • Employment Reference Verification
  • ASG Employee Application
  • DOT Medical Records
  • PSP Report
  • Annual Motor Vehicle Drivers Certification of Violations
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Form W-4

Purpose.

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

Exemption from withholding.

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

Note.

If another person can claim you as a dependent on his or her tax return, you 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).

Exemptions.

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 job 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 www.irs.gov/w4

Right to be Free of Gender Inequity or Bias in Pay, Compensation, Benefits or Other Terms and Conditions of Employment

New Jersey and federal laws prohibit employers from discriminating against an individual with respect to his/her pay, compensation, benefits, or terms, conditions or privileges of employment because of the individual’s sex.

FEDERAL LAW
Title VII of the Civil Rights Act of 1964 prohibits employment discrimination based on, among other things, an individual’s sex. Title VII claims must be filed with the United States Equal Employment Opportunity Commission (EEOC) before they can be brought in court. Remedies under Title VII may include an order restraining unlawful discrimination, back pay, and compensatory and punitive damages.

The Equal Pay Act of 1963 (EPA) prohibits discrimination in compensation based on sex. EPA claims can be filed either with the EEOC or directly with the court. Remedies under the EPA may include the amount of the salary or wages due from the employer, plus an additional equal amount as liquidated damages.

Please be mindful that in order for a disparity in compensation based on sex to be actionable under the EPA, it must be for equal work on jobs the performance of which requires equal skill, effort, and responsibility, and which are performed under similar working conditions.

There are strict time limits for filing charges of employment discrimination. For further information, contact the EEOC at 800-669-4000 or at www.eeoc.gov

NEW JERSEY LAW

The New Jersey Law Against Discrimination (LAD) prohibits employment discrimination based on, among other things, an individual’s sex. LAD claims can be filed with the New Jersey Division on Civil Rights (NJDCR) or directly in court. Remedies under the LAD may include an order restraining unlawful discrimination, back pay, and compensatory and punitive damages.

Another State law, N.J.S.A. 34:11-56.1 et seq., prohibits discrimination in the rate or method of payment of wages to an employee because of his or her sex. Claims under this wage discrimination law may be filed with the New Jersey Department of Labor and Workforce Development (NJDLWD) or directly in court. Remedies under this law may include the full amount of the salary or wages owed, plus an additional equal amount as liquidated damages.

Please be mindful that under the State wage discrimination law a differential in pay between employees based on a reasonable factor or factors other than sex shall not constitute discrimination.

There are strict time limits for filing charges of employment discrimination. For more information regarding LAD claims, contact the NJDCR at 609-292-4605 or at www.njcivilrights.gov. For information concerning N.J.S.A. 34:11-56.1 et seq., contact the Division of Wage and Hour Compliance within the NJDLWD at 609-292-2305 or at http://Iwd.state.nj.us

This notice must be conspicuously displayed.

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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