Employment Application

Employer Information - Employment Location

No PO Box, RD or RR

Certification

Under penalties of perjury, I (we) declare that I (we) have examined this information, including all accompanying schedules and statements and to the best of my (our) belief, they are true, correct and complete.

For information on obtaining the appropriate MUNICIPALITY (City, Borough, Township), PSD CODES, and EIT (Earned Income Tax) RATES, please refer to the Pennsylvania Department of Community & Economic Development website: dced.pa.gov/Act32

Purpose. Complete Form REV-491 so that your employer can withhold the correct Pennsylvania personal income tax from your pay. Complete a new Form REV-419 every year or when your personal or financial situation changes. Photocopies of this form are acceptable.

Note: Unless the state of residence changes, residents of the reciprocal states listed in the next paragraph do not need to refile this application every year.

Who is Eligible for Nonwithholding? You may be entitled to nonwitholding of PA personal income tax if you incurred no liability for income tax the preceding tax year and/or you anticipate that you will incur no liability for income tax during the current year, according to the Special Tax Provisions of section 304 of the Tax Reform Code, the Servicemember Civil Relief Act (SCRA) of as a resident of the reciprocal state of Indiana, Maryland, New Jersey, Ohio, Virginia or West Virginia and your employer agrees to withhold the income tax from that state.

When to Claim? File this certificate with your employer as soon as you determine you are entitled to claim nonwithohlding. You must file a certificate each year you are eligible (see Note above for an exception). If you are employed by more than one employer you must file a separate REV-419 with each employer.

Responsibilities of Employee. You must revoke this certification within 10 days from the day you anticipate you will incur PA personal income tax liability for the current tax year. To discontinue or revoke this certification, submit notification in writing to your employer. Claimants who qualify for complete Tax Forgiveness under section 304 of the Tax Reform Code must file a PA-40, Pennsylvania Personal Income Tax Return, and Schedule SP to claim Tax Forgiveness even if they are eligible for non-withholding.

Under the SCRA, as amended by the Military Spouses Residency Relief Act, you may be exempt from PA personal Income tax on your wages if (i) your spouse is a member of the armed forces present in PA compliance

with military orders; (ii) you are present in PA solely to be with your spouse; and (iii) you and your spouse both maintain the same domicile (state residency) in another state. If you claim exemption under the SCRA, enter your state of domicile (legal residence) on Line d below and attach a copy of your spousal military Identification card and your spouse's current military orders to form REV-419.

Responsibility of Employer. If you agree not to withhold PA tax because your employee is a resident of a reciprocal state, you must withhold the other state's tax. Retain Form REV-419 with your records. You are required to submit a copy of this certificate and accompanying attachments to the PA DEPARTMENT OF REVENUE, BUREAU OF INDIVIDUAL TAXES, PO BOX 280507, HARRISBURG, PA 17128-0507, when:

  1. you have reason to believe this certificate is incorrect;
  2. the PA taxable gross compensation of any employee who claimed either exemption from nonwithholding a or b below exceeds $1,625 for any quarter;
  3. the employee claims an exemption from withholding o nthe basis of residence in a reciprocal state (Indiana, Maryland, New Jersey, Ohio, Virginia or West Virginia) and therefore, you agree to withhold income tax of the employee's state or residence; or
  4. the employee claims an exemption from witholding under the SCRA as amended by the Military Spouses Residency Relief Act.

Department's Responsibility. Upon receipt of any exemption application, the department will make a determination and notify the employer if a change is required. If the department disapproves the application, the employer must immediately commence withholding at the regular rate. Once a certificate is revoked by the department, the employer must send a new application received from the employee to the department for approval before implementing the nonwitholding.

Under penalties of perjury, I certify that I did not incur any Pennsylvania personal income tax liability during the preceding tax year and/or I do not expect to incur any liability during the current tax year based on the reason(s) indicated above.

Notification to Employees of Their Rights and Duties Under the PA Workers' Compensation Act Section 306 (f.1)(1)(i)

The Pennsylvania Workers' Compensation Act requires that employees be given written notice of their rights and duties under Sec. 306 (f.1)(1)(i) of the Act if a list of designated health care providers is established by the employer. Text of Section 306 f.1)(1)(i): The employer shall provide payment in accordance with this section for reasonable surgical and medical services, services rendered by physicians or other health care providers, including an additional opinion when invasive surgery may be necessary, medicines and supplies, as when needed. Provided an employer establishes a list of at least six designated health care providers, no more than four or whom may be coordinated care organization and no fewer than three of whom shall be physicians, the employee shall be required to visit one of the physicians or other health care providers so designated and shall continue to visit the same or another designated physician or health care provider for a period of ninety (90) days from the date of the first visit: provided, however, that the employer shall not include on the list of physician or other health care provider who is employed, owned or controlled by the employer or the employer's insurer unless employment, ownership or control is disclosed on the list. Should invasive surgery for an employee be prescribed by a physician or other health care provider so designated by the employer, the employee shall be permitted to receive an additional opinion from any health care provider of the employee's own choice. If the additional opinion differs from the opinion provided by the physician or health care provider so designated by the employer, the employee shall determine which course of treatment to follow: provided, that the that the second opinion provides a specific and detailed course of treatment. If the employee chooses to follow the procedures designated in the second opinion, such procedures shall be performed by one of the physicians or other health care providers so designated by the employer for a period of ninety (90) days from the date of the visit to the physician or other health care provider of the employee's own choice. Should the employee not comply with the foregoing, the employer will be relieved from liability for the payment for the services rendered during such applicable period. It shall be the duty of the employer to provide a clearly written notification of the employee's rights and duties under this section to the employee. The employer shall further ensure that the employee has been informed, and that he understands these rights and duties. This duty sh21II be evidenced only by the employee's written acknowledgment of having been informed and having understood his rights and duties. Any failure of the employer to provide and evidence such notification shall relieve the employee from any notification duty owed, notwithstanding any provision of this act to the contrary, and the employer shall remain liable for all rendered treatment. Subsequent treatment may be provided by any health care provider of the employee's own choice. Any employee who, next following termination of the applicable period, is provided treatment from a nondesignated health care provider shall notify the employer within five (5) days of the first visit to said health care provider. Failure to so notify the employer will relieve the employer from liability for the payment for the services rendered prior to appropriate notice if such services are determined pursuant to paragraph (6) to have been unreasonable or unnecessary.

Rights and Duties

As an employee of a commonwealth working at a location where a list of designated health care providers has been established posted, you have the right to seek emergency medical treatment from any provider; for post-emergency and other injuries, you must obtain treatment for work-related injuries and illnesses from a designated health care provider for 90 days. The penalty for not using a designated health care provider is that the commonwealth is not liable for the medical bills incurred. Specific rights and duties are:

  • The duty to obtain treatment for work-related injuries and illnesses from one or more of the designated health care providers for 90 days from the date of the first visit to a designated provider.
  • The right to seek emergency medical treatment from any provider, but subsequent non-emergency treatment shall be by a designated is obtained from a designated provider during the 90-day period.
  • The right to have all reasonable medical supplies and treatment related to the injury paid for by your employer as long as treatment is obtained from a designated provider during the 90-day period.
  • The right, during this 90-day period, to switch from one designated health care provider to another designated provider.
  • The right to seek treatment from a provider if you are referred to that provider by a designated provider.
  • The right to an additional opinion from a provider of your choice when invasive surgery is prescribed by the designated provider.
  • The right to seek treatment from any health care provider after the 90-day period has ended.
  • The duty to notify your employer of treatment by a non-designated provider (after the 90-day period) within 5 days of the first visit to that provider. The employer may not be required to pay for treatment rendered by a non designated provider prior to receiving this notification.

I acknowledged that I have been informed of my rights and duties under Sec. 306 (f.1)(1)(i) and that I understand them to the extent they are explained above.

SECTION 2: GENERAL INFORMATION

SECTION 3: EMPLOYMENT REFERENCES

Please reference the last three places where you have worked.

SECTION 4: ACKNOWLEDGMENT AND UNDERSTANDING

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. 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.

LOAN AND REPAYMENT AGREEMENT

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.

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.

THE PARTIES HAVE READ AND UNDERSTOOD THE FOREGOING TERMS AND CONDITIONS AND AGREETO THEM AS OF THE DATEOF THE SIGNINGOF 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 EXECUTRD DUPLICATE OF THIS AGREEMENT.

Disclosure And Authorization For Consumer Reports

Disclosure

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.

Authorization

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: www.wescreenusa.com.

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.

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.

RESTRICTION QUESTIONNAIRE

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.

TAX CREDIT QUESTIONNAIRE

EMPLOYER SECTION

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

*Ifyes, please provide information below.
*If yes, please provide information below.
*If you checked yes please provide a copy of your SSI documentation.
*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.

*If yes, please provide information below, if no, please continue to question #6.
From
To
* If yes, dates of unemployment.
From
To

Additional Tax Credits

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

CA Residents

SC Residents

Click here to read and acknowledge receipt of the Action Staffing Group Rules and Regulations packet

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.

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 www.irs.gov/formspubs. 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.

LONG-TERM UNEMPLOYMENT RECIPIENT SELF-ATTESTATION FORM Work Opportunity Tax Credit (WOTC) Program

Instructions: This Self-Attestation Form(SAF) is to be completed, signed, and dated by the new hire only. Employers or consultants submit this SAF to the State Workforce Agency with IRS Form 8850 or if filed separately, with ETA Form 9061 (or ETA Form 9062) for each certification request filed for the new target group.

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

Privacy Act Notice

The Internal Revenue Code of 1986, Section 51, as amended and its enacting legislation, P.L 104-188, specify that the State Workforce Agencies are the “designated” agencies responsible for administering the WOTC certification procedures of this program. The information you have provided completing this form will be disclosed by youremployer to the State Workforce Agency. Provision of this information is voluntary; however the information is required to determine your employer’s eligibility for the federal tax credit.

Public Burden Statement

Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Respondents’ obligation to complete this form is required to obtain or retain benefits (P.L111-5). Public reporting burden is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of Information. Send comments regarding this burden estimate to the U.S. Department of Labor, Division of National Programs Tools Technical Assistance, Room 04510, Washington,D.C.20210 (Paperwork Reduction Project 1205-0371). Please do not submit completed fonns to this address.

Form W-4 Employee's Withholding Certificate

Step 1: Enter Personal Information

Step 2: Multiple Jobs or Spouse Works

Complete this step if you (1) hold more than 1 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.

TIP: To be accurate, submit a 2020 Form 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 income will be $200,000 or less ($400,000 or less if married filing jointly):
Enter 0 (zero) if no qualifying dependents.

Step 4 (optional): Other Adjustments

Enter 0 (zero) if sections if a,b,c do not apply.

Step 5: Sign Here

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)
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.
Do Not Write In This Space
Reset Signature
Click below and sign your name on the line as you normally would.
(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)
Click below and sign your name on the line as you normally would.
Reset Signature
Today's Date

Section 2. Employer or Authorized Representative Review and Verification

Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee’s first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the “Lists of Acceptable Documents.” )

List A

Identity and Employment Authorization

List B

Identity

List C

Employment Authorization
Do Not Write In This Space

Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States.

See instructions for exemptions
Today's Date

Section 3. Reverification and Rehires

To be completed and signed by employer or authorized representative.
A. New Name (if applicable)
B. Date of Rehire (if applicable)

C. If the employee’s previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below

Today's Date

Lists of Acceptable Documents.

All documents must be UNEXPIRED

Employees may present one selection from List A or a combination of one selection from List B and one selection from List C

Documents that Establish Both Identity and Employment Authorization

  1. U.S. Passport or U.S. Passport Card
  2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551)
  3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa
  4. Employment Authorization Document that contains a photograph (Form I-776)
  5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status:
    a. Foreign passport; and
    b. Form I-94 or Form I-94A that has the following:
    (1) The same name as the passport; and
    (2) An endorsement of the alien’s nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.
  6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating the nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

Documents that Establish Identity

  1. Driver’s license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye, color, and address
  2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address
  3. School ID card with photograph
  4. Voter’s registration card
  5. U.S. Military card or draft record
  6. Military dependent’s ID card
  7. U.S. Coast Guard Merchant Mariner Card
  8. Native American tribal document
  9. Driver’s license issued by a Canadian government authority

For persons under age 18 who are unable to present a document listed above:

  1. School record or report card
  2. Clinic, doctor, or hospital record
  3. Day-care or nursery school record

Documents that Establish Employment Authorization

  1. A Social Security Account Number card, unless the card includes one of the following restrictions:
    (1) NOT VALID FOR EMPLOYMENT
    (2) VALID FOR WORK ONLY WITH INS AUTHORIZATION
    (3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION
  2. Certification of report of birth issued by the Department of State (Forms DS-1350, FS 545, FS-240)
  3. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal.
  4. Native American tribal document
  5. U.S. Citizen ID Card (Form I-197)
  6. Identification Card for Use of Resident Citizen in the United States (Form I-179)
  7. Employment authorization document issued by the Department of Homeland Security

If you do not have a scanner follow these instructions to use your phone:

1) Take a picture of the documents one by one
2) Email yourself the photos
3) Save the photos to your computer
4) Upload them using the upload feature below

Select the document(s) to be able to upload.

You may present one selection from List A or a combination of one selection from List B and one selection from List C

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.

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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