1502 Augusta Drive • Suite 100 •Houston, TX 77057 • 1-888-667-3690

Transcription

EMPLOYEE ENROLLMENT FORM
(Complete this page on a computer with Adobe Acrobat and all forms will be populated)
Client __________________________________________________________
Employee Information
Last Name ____________________________ First Name ________________________ MI ______
Maiden Name ________________________
Male
Female
Email Address ___________________
Address _______________________________ City ________________ State _______ Zip Code _________
SS # _______________ Driver’s License _______________ DOB _______________
Primary Phone # ______________ Alternate Phone # ______________ Cell Phone # ____________
Can you legally work in the United States?
Yes
No
Emergency Notification: Name ____________________________________ Phone # _____________
Please list the last (3) employers:
1)
Name of Company ____________________________ Start Date ___________ End Date ___________
Supervisor’s Name ___________________________ May we contact the supervisor? ________
2)
3)
I certify that the responses contained in this questionnaire are true and correct to the best of my knowledge and understand
that false statements or responses shall be grounds for dismissal.
I understand and agree that my employment is for no definite period and I may be terminated at any time without prior notice.
I also understand that should the staff leasing agreement between ProSource Management Solutions and the
Client/Employer be terminated, my employment with ProSource Management Solutions is terminated and my last
payment will be by Check.
I authorize Investigation of the statements contained in this application and authorize contacting the employers listed above
regarding information concerning my previous employment and other pertinent information they may have, personal or
otherwise. I understand and agree the company ( or affiliate) has an employment dispute resolution policy and procedure. The
terms of this procedure are incorporated by reference in this application. A copy is contained in the packet. This procedure is
the required and exclusive remedy for applicants, employees, and the company (and the on-site employer) to resolve disputes
between all such parties. By completing and submitting this application, I agree to resolve any dispute between ProSource/and
client and me arising out of or related to this application exclusively according to the terms of the employment dispute resolution
procedure.
Employee Signature __________________________________
Date _________________
Employee Information: (To be filled out by employer)
HOURLY
SALARY
Job Title ______________________________________ New Hire Date ___________
Rate of Pay _______________________
Full-time OR
Part-time
Exempt OR
Nonexempt
When packet completed, please print the packet, fill in remaining necessary information, SIGN where necessary and
give to your onsite payroll representative.
1502 Augusta Drive • Suite 100 •Houston, TX 77057 • 1‐888‐667‐3690 Disclosure Statement
New Hire Packet
ProSource Management Solutions (ProSource) is licensed as a staff leasing
company by the State of Texas and is generally governed by Chapter 91 of the
Texas Labor Code. When ProSource enters into a contractual agreement with a
Client, an onsite employer, such as your employer, it is the intention of the Staff
Leasing Company and the Client that Staff Leasing Company shall be the
"Administrative Employer" only as to all Leased Employees of the Client company,
and the Client retains total and complete operational control over the Employees of
the Client company. You as the Employee understand that Staff Leasing Company
is an “outsourcing vendor” and contracts with clients (worksite employers) merely to
perform administrative functions, including payroll, providing benefits, regulatory
paperwork, and other functions as requested, as may be agreed to by Staff Leasing
Company and the Client. As such I understand my onsite or worksite employer is
the qualifying employer for the purposes of the Family Medical Leave Act (FMLA)
and as the onsite or worksite employer has the responsible for administration of The
Americans with Disabilities Act (ADA).
The undersigned confirms I understand the relationship and the information
provided in the attached documents, herein referred to as the “New Hire Packet”
and that the packet contains forms which make reference to “employee”,
“employment” and “employer” and I understand these terms as used and as
explained herein.
I further state that I understand there is no contractual relationship between the
undersigned and ProSource or the Client Company/onsite Employer.
Employee’s Printed Name _____________________________________
Employee Signature _________________________________ Date ____________
1502 Augusta Drive • Suite 100 •Houston, TX 77057 • 1‐888‐667‐3690 EMPLOYEE INFORMATION FORM
EMPLOYEE NAME ___________________________________________
MALE
FEMALE
ADDRESS: (Number & Street) ___________________________________________________
(City, State & Zip) _____________________________________________________________
HOME PHONE: _________________
CELL PHONE: _________________
ADDITIONAL PHONE: _____________
SOCIAL SECURITY#: ____________________
DRIVER’S LICENSE #: ____________________
DATE OF BIRTH: ____________________ Can you legally work in the United States? _________
In case of emergency, notify: Name:______________________________ Phone:_______________
I certify that the responses contained in this questionnaire are true and correct to the best of my
knowledge and understand that false statements or responses shall be grounds for dismissal.
I understand and agree that my employment is for no definite period and I may, regardless of the date
of payment of my wages and/or salary, be terminated at any time without prior notice. I also
understand that should the staff leasing agreement between ProSource Management Solutions and the
Client/Employer be terminated, my employment with ProSource Management Solutions is terminated.
EMPLOYEE SIGNATURE__________________________
DATE________________
TO BE COMPLETED BY AUTHORIZED PERSONNEL AT CLIENT COMPANY
POSITION TITLE of EMPLOYEE: _____________________________________________________
CLIENT COMPANY NAME: __________________________________________________________
SUMMARY OF DUTIES: _______________________________
DEPARTMENT________________________________________
HOURLY or
SALARY
EXEMPT or
RATE OF PAY:______________
NONEXEMPT
FULL TIME OR
PART TIME
PAY FREQ: _______________________
PEO HIRE DATE: ____________________
ORIGINAL CLIENT HIRE DATE: ____________________
If required:
Printed name of person authorizing this data: ________________________________________________
Signature of person authorizing this data: ________________________________ Date:____________________
*Personnel Action Form to be initiated with this form.
1502 Augusta Drive • Suite 100 •Houston, TX 77057 • 1‐888‐667‐3690 APPLICATION FOR EMPLOYMENT SHORT FORM
(To accompany Employee Information form)
Name ______________________________ Address ________________________________________
City __________________ State _____ Zip Code __________ Phone _________ Cell Phone ________
Additional Phone _______________ Social Security # ________________ Date of Birth _____________
Can you legally work in the United States?__________
Licensures & Certifications ______________________________________________________________
Please list the last three employers:
1) Name of Company _____________________________ Start Date __________ End Date__________
Address _____________________________________________________________________________
Supervisors name _____________________________________ May we contact the supervisor? ______
Address _____________________________________________________________________________
Address _____________________________________________________________________________
Have you been convicted of a felony in the last five (5) years? ____________ If yes, please explain.
Will not necessarily exclude you from employment) ___________________________________________
____________________________________________________________________________________
I CERTIFY THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY
KNOWLEDGE AND UNDERSTAND THAT, IF EMPLOYED, FALSE STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS
FOR TERMINATION.
I AUTHORIZE INVESTIGATION OF THE STATEMENTS CONTAINED IN THIS APPLICATION AND I AUTHORIZE CONTACTING
THE EMPLOYERS LISTED ABOVE REGARDING INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND OTHER
PERTINENT INFORMATION THEY MAY HAVE, PERSONAL OR OTHERWISE. I HEREBY RELEASE ALL CONTACTED FROM ALL
LIABILITY FOR DAMAGE THAT MAY RESULT FROM THE UTILIZATION OF INFORMATION GIVEN AND RECEIVED.I
UNDERSTAND AND AGREE NO REPRESENTATIVE OF THE COMPANY (PROSOURCE OR AFFILIATES OR THE ON-SITE
EMPLOYER) RECEIVING THIS APPLICATION IS AUTHORIZED TO CONTRACT WITH ME FOR EMPLOYMENT EXCEPT THE
COMPANY PRESIDENT AND/OR HIS OR HER DESIGNEE. BY COMPLETING AND SUBMITTING THIS APPLICATION FOR
EMPLOYMENT TO PROSOURCE MANAGEMENT SOLUTIONS, A DBA OF ST DESIGN CORPORATION OR AFFILIATES (THE
COMPANY),
I UNDERSTAND AND AGREE THE COMPANY (OR AFFILIATE) HAS AN EMPLOYMENT DISPUTE
RESOLUTION POLICY AND PROCEDURE. THE TERMS OF THIS PROCEDURE ARE INCORPORATED BY REFERENCE IN THIS
APPLICATION. A COPY IS CONTAINED IN THIS PACKET. THIS PROCEDURE IS THE REQUIRED AND EXCLUSIVE REMEDY
FOR APPLICANTS, EMPLOYEES, AND THE COMPANY (AND THE ON-SITE EMPLOYER) TO RESOLVE DISPUTES
BETWEEN ALL SUCH PARTIES.
BY COMPLETING AND SUBMITTING THIS APPLICATION I AGREE TO RESOLVE ANY
DISPUTE BETWEEN PROSOURCE/AND CLIENT AND ME ARISING OUT OF OR RELATED TO THIS APPLICATION EXCLUSIVELY
ACCORDING TO THE TERMS OF THE EMPLOYMENT DISPUTE RESOLUTION PROCEDURE.
Employee Signature _____________________________________ Date ________________
1502 Augusta Drive • Suite 100 •Houston, TX 77057 • 1‐888‐667‐3690 Form W-4 (2009)
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 2009 expires February 16, 2010. See
Pub. 505, Tax Withholding and Estimated Tax.
Note. You cannot claim exemption from
withholding if (a) your income exceeds $950
and includes more than $300 of unearned
income (for example, interest and dividends)
and (b) another person can claim you as a
dependent on their tax return.
Basic instructions. If you are not exempt,
complete the Personal Allowances Worksheet
below. The worksheets on page 2 further adjust
your withholding allowances based on itemized
deductions, certain credits, adjustments to
income, or two-earner/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 flat amount or
percentage of wages.
Head of household. Generally, you may 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
child or dependent care expenses and the
child tax credit may be claimed using the
Personal Allowances Worksheet below. See
Pub. 919, How Do I Adjust My Tax
Withholding, 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. 919 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 on all jobs using worksheets from only
one Form W-4. Your withholding usually will
be most accurate when all allowances are
claimed on the Form W-4 for the highest
paying job and zero allowances are claimed on
the others. See Pub. 919 for details.
Nonresident alien. If you are a nonresident
alien, see the Instructions for Form 8233
before completing this Form W-4.
Check your withholding. After your Form W-4
takes effect, use Pub. 919 to see how the
amount you are having withheld compares to
your projected total tax for 2009. See Pub.
919, especially if your earnings exceed
$130,000 (Single) or $180,000 (Married).
Personal Allowances Worksheet (Keep for your records.)
Enter “1” for yourself if no one else can claim you as a dependent
● You are single and have only one job; or
B Enter “1” if:
● You are married, have only one job, and your spouse does not work; or
● Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.
A
$
A
%
B
C Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or
C
more than one job. (Entering “-0-” may help you avoid having too little tax withheld.)
D
D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return
E
E Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above)
F
F Enter “1” if you have at least $1,800 of child or dependent care expenses for which you plan to claim a credit
(Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)
G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.
● If your total income will be less than $61,000 ($90,000 if married), enter “2” for each eligible child; then less “1” if you have three or more eligible children.
● If your total income will be between $61,000 and $84,000 ($90,000 and $119,000 if married), enter “1” for each eligible
G
child plus “1” additional if you have six or more eligible children.
H Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.) © H
● If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions
For accuracy,
and Adjustments Worksheet on page 2.
complete all
worksheets
● If you have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed
$40,000 ($25,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld.
that apply.
● If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.
$
Cut here and give Form W-4 to your employer. Keep the top part for your records.
Form
W-4
Department of the Treasury
Internal Revenue Service
1
5
6
7
OMB No. 1545-0074
Employee’s Withholding Allowance Certificate
©
Whether you are entitled to claim a certain number of allowances or exemption from withholding is
subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
Type or print your first name and middle initial.
Last name
2
2009
Your social security number
Home address (number and street or rural route)
3
City or town, state, and ZIP code
4 If your last name differs from that shown on your social security card,
check here. You must call 1-800-772-1213 for a replacement card. ©
Single
Married
Married, but withhold at higher Single rate.
Note. If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.
5
Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2)
6
Additional amount, if any, you want withheld from each paycheck
I claim exemption from withholding for 2009, and I certify that I meet both of the following conditions for exemption.
● Last year I had a right to a refund of all federal income tax withheld because I had no tax liability and
● This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.
©
If you meet both conditions, write “Exempt” here
7
$
Under penalties of perjury, I declare that I have examined this certificate and to the best of my knowledge and belief, it is true, correct, and complete.
Employee’s signature
(Form is not valid unless you sign it.)
8
©
Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.)
For Privacy Act and Paperwork Reduction Act Notice, see page 2.
Date
9 Office code (optional) 10
Cat. No. 10220Q
©
Employer identification number (EIN)
Form
W-4
(2009)
Form W-4 (2009)
Page
2
Deductions and Adjustments Worksheet
Note. Use this worksheet only if you plan to itemize deductions, claim certain credits, adjustments to income, or an additional standard deduction.
1 Enter an estimate of your 2009 itemized deductions. These include qualifying home mortgage interest,
charitable contributions, state and local taxes, medical expenses in excess of 7.5% of your income, and
miscellaneous deductions. (For 2009, you may have to reduce your itemized deductions if your income
1 $
is over $166,800 ($83,400 if married filing separately). See Worksheet 2 in Pub. 919 for details.)
$11,400 if married filing jointly or qualifying widow(er)
2 Enter:
$ 8,350 if head of household
2 $
$ 5,700 if single or married filing separately
3 Subtract line 2 from line 1. If zero or less, enter “-0-”
3 $
4 Enter an estimate of your 2009 adjustments to income and any additional standard deduction. (Pub. 919)
4 $
5 $
5 Add lines 3 and 4 and enter the total. (Include any amount for credits from Worksheet 8 in Pub. 919.)
6 $
6 Enter an estimate of your 2009 nonwage income (such as dividends or interest)
7 $
7 Subtract line 6 from line 5. If zero or less, enter “-0-”
8 Divide the amount on line 7 by $3,500 and enter the result here. Drop any fraction
8
9 Enter the number from the Personal Allowances Worksheet, line H, page 1
9
10 Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet,
also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1 10
$
%
Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.)
Note. Use this worksheet only if the instructions under line H on page 1 direct you here.
1 Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet)
2 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if
you are married filing jointly and wages from the highest paying job are $50,000 or less, do not enter more
than “3.”
1
2
3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter
“-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet
3
Note. If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4–9 below to calculate the additional
withholding amount necessary to avoid a year-end tax bill.
4
5
6
7
8
9
Enter the number from line 2 of this worksheet
4
5
Enter the number from line 1 of this worksheet
Subtract line 5 from line 4
Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here
Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed
Divide line 8 by the number of pay periods remaining in 2009. For example, divide by 26 if you are paid
every two weeks and you complete this form in December 2008. Enter the result here and on Form W-4,
line 6, page 1. This is the additional amount to be withheld from each paycheck
Table 1
Married Filing Jointly
If wages from LOWEST
paying job are—
$0 - $4,500
4,501 - 9,000
9,001 - 18,000
18,001 - 22,000
22,001 - 26,000
26,001 - 32,000
32,001 - 38,000
38,001 - 46,000
46,001 - 55,000
55,001 - 60,000
60,001 - 65,000
65,001 - 75,000
75,001 - 95,000
95,001 - 105,000
105,001 - 120,000
120,001 and over
Enter on
line 2 above
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
$
$
9
$
Table 2
All Others
If wages from LOWEST
paying job are—
$0
6,001
12,001
19,001
26,001
35,001
50,001
65,001
80,001
90,001
120,001
6
7
8
- $6,000
- 12,000
- 19,000
- 26,000
- 35,000
- 50,000
- 65,000
- 80,000
- 90,000
- 120,000
and over
Married Filing Jointly
Enter on
line 2 above
If wages from HIGHEST
paying job are—
0
1
2
3
4
5
6
7
8
9
10
$0 - $65,000
65,001 - 120,000
120,001 - 185,000
185,001 - 330,000
330,001 and over
Privacy Act and Paperwork Reduction Act Notice. We ask for the information on
this form to carry out the Internal Revenue laws of the United States. The Internal
Revenue Code requires this information under sections 3402(f)(2)(A) and 6109 and
their regulations. Failure to provide a properly completed form will result in your
being treated as a single person who claims no withholding allowances; providing
fraudulent information may also subject you to penalties. Routine uses of this
information include giving it to the Department of Justice for civil and criminal
litigation, to cities, states, the District of Columbia, and U.S. commonwealths and
possessions for use in administering their tax laws, and using it in the National
Directory of New Hires. 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.
All Others
If wages from HIGHEST
Enter on
line 7 above paying job are—
$550
910
1,020
1,200
1,280
$0 - $35,000
35,001 90,000
90,001 - 165,000
165,001 - 370,000
370,001 and over
Enter on
line 7 above
$550
910
1,020
1,200
1,280
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 OMB
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 Code section 6103.
The average time and expenses required to complete and file this form will vary
depending on individual circumstances. For estimated averages, see the
instructions for your income tax return.
If you have suggestions for making this form simpler, we would be happy to hear
from you. See the instructions for your income tax return.
OMB No. 1615-0047; Expires 06/30/09
Form I-9, Employment
Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services
Instructions
Read all instructions carefully before completing this form.
Anti-Discrimination Notice. It is illegal to discriminate against
any individual (other than an alien not authorized to work in the
United States) in hiring, discharging, or recruiting or referring for a
fee because of that individual's national origin or citizenship status.
It is illegal to discriminate against work-authorized individuals.
Employers CANNOT specify which document(s) they will accept
from an employee. The refusal to hire an individual because the
documents presented have a future expiration date may also
constitute illegal discrimination. For more information, call the
Office of Special Counsel for Immigration Related Unfair
Employment Practices at 1-800-255-8155.
in Section 2 evidence of employment authorization that
contains an expiration date (e.g., Employment Authorization
Document (Form I-766)).
Preparer/Translator Certification
The Preparer/Translator Certification must be completed if
Section 1 is prepared by a person other than the employee. A
preparer/translator may be used only when the employee is
unable to complete Section 1 on his or her own. However, the
employee must still sign Section 1 personally.
Section 2, Employer
What Is the Purpose of This Form?
The purpose of this form is to document that each new
employee (both citizen and noncitizen) hired after November
6, 1986, is authorized to work in the United States.
When Should Form I-9 Be Used?
All employees, citizens, and noncitizens hired after November
6, 1986, and working in the United States must complete
Form I-9.
Filling Out Form I-9
For the purpose of completing this form, the term "employer"
means all employers including those recruiters and referrers
for a fee who are agricultural associations, agricultural
employers, or farm labor contractors. Employers must
complete Section 2 by examining evidence of identity and
employment authorization within three business days of the
date employment begins. However, if an employer hires an
individual for less than three business days, Section 2 must be
completed at the time employment begins. Employers cannot
specify which document(s) listed on the last page of Form I-9
employees present to establish identity and employment
authorization. Employees may present any List A document
OR a combination of a List B and a List C document.
This part of the form must be completed no later than the time
of hire, which is the actual beginning of employment.
Providing the Social Security Number is voluntary, except for
employees hired by employers participating in the USCIS
Electronic Employment Eligibility Verification Program (EVerify). The employer is responsible for ensuring that
Section 1 is timely and properly completed.
If an employee is unable to present a required document (or
documents), the employee must present an acceptable receipt
in lieu of a document listed on the last page of this form.
Receipts showing that a person has applied for an initial grant
of employment authorization, or for renewal of employment
authorization, are not acceptable. Employees must present
receipts within three business days of the date employment
begins and must present valid replacement documents within
90 days or other specified time.
Noncitizen Nationals of the United States
Employers must record in Section 2:
Section 1, Employee
Noncitizen nationals of the United States are persons born in
American Samoa, certain former citizens of the former Trust
Territory of the Pacific Islands, and certain children of
noncitizen nationals born abroad.
Employers should note the work authorization expiration
date (if any) shown in Section 1. For employees who indicate
an employment authorization expiration date in Section 1,
employers are required to reverify employment authorization
for employment on or before the date shown. Note that some
employees may leave the expiration date blank if they are
aliens whose work authorization does not expire (e.g., asylees,
refugees, certain citizens of the Federated States of Micronesia
or the Republic of the Marshall Islands). For such employees,
reverification does not apply unless they choose to present
1.
2.
3.
4.
5.
Document title;
Issuing authority;
Document number;
Expiration date, if any; and
The date employment begins.
Employers must sign and date the certification in Section 2.
Employees must present original documents. Employers may,
but are not required to, photocopy the document(s) presented.
If photocopies are made, they must be made for all new hires.
Photocopies may only be used for the verification process and
must be retained with Form I-9. Employers are still
responsible for completing and retaining Form I-9.
Form I-9 (Rev. 02/02/09) N
For more detailed information, you may refer to the
USCIS Handbook for Employers (Form M-274). You may
obtain the handbook using the contact information found
under the header "USCIS Forms and Information."
Information about E-Verify, a free and voluntary program that
allows participating employers to electronically verify the
employment eligibility of their newly hired employees, can be
obtained from our website at www.uscis.gov/e-verify or by
calling 1-888-464-4218.
Section 3, Updating and Reverification
Employers must complete Section 3 when updating and/or
reverifying Form I-9. Employers must reverify employment
authorization of their employees on or before the work
authorization expiration date recorded in Section 1 (if any).
Employers CANNOT specify which document(s) they will
accept from an employee.
A. If an employee's name has changed at the time this form
is being updated/reverified, complete Block A.
B. If an employee is rehired within three years of the date
this form was originally completed and the employee is
still authorized to be employed on the same basis as
previously indicated on this form (updating), complete
Block B and the signature block.
C. If an employee is rehired within three years of the date
this form was originally completed and the employee's
work authorization has expired or if a current
employee's work authorization is about to expire
(reverification), complete Block B; and:
1. Examine any document that reflects the employee
is authorized to work in the United States (see List
A or C);
2. Record the document title, document number, and
expiration date (if any) in Block C; and
3. Complete the signature block.
Note that for reverification purposes, employers have the
option of completing a new Form I-9 instead of completing
Section 3.
What Is the Filing Fee?
There is no associated filing fee for completing Form I-9. This
form is not filed with USCIS or any government agency. Form
I-9 must be retained by the employer and made available for
inspection by U.S. Government officials as specified in the
Privacy Act Notice below.
USCIS Forms and Information
General information on immigration laws, regulations, and
procedures can be obtained by telephoning our National
Customer Service Center at 1-800-375-5283 or visiting our
Internet website at www.uscis.gov.
Photocopying and Retaining Form I-9
A blank Form I-9 may be reproduced, provided both sides are
copied. The Instructions must be available to all employees
completing this form. Employers must retain completed Form
I-9s for three years after the date of hire or one year after the
date employment ends, whichever is later.
Form I-9 may be signed and retained electronically, as
authorized in Department of Homeland Security regulations
at 8 CFR 274a.2.
Privacy Act Notice
The authority for collecting this information is the
Immigration Reform and Control Act of 1986, Pub. L. 99-603
(8 USC 1324a).
This information is for employers to verify the eligibility of
individuals for employment to preclude the unlawful hiring, or
recruiting or referring for a fee, of aliens who are not
authorized to work in the United States.
This information will be used by employers as a record of
their basis for determining eligibility of an employee to work
in the United States. The form will be kept by the employer
and made available for inspection by authorized officials of
the Department of Homeland Security, Department of Labor,
and Office of Special Counsel for Immigration-Related Unfair
Employment Practices.
Submission of the information required in this form is
voluntary. However, an individual may not begin employment
unless this form is completed, since employers are subject to
civil or criminal penalties if they do not comply with the
Immigration Reform and Control Act of 1986.
To order USCIS forms, you can download them from our
website at www.uscis.gov/forms or call our toll-free number at
1-800-870-3676. You can obtain information about Form I-9
from our website at www.uscis.gov or by calling
1-888-464-4218.
EMPLOYERS MUST RETAIN COMPLETED FORM I-9
DO NOT MAIL COMPLETED FORM I-9 TO ICE OR USCIS
Form I-9 (Rev. 02/02/09) N Page 2
Paperwork Reduction Act
An agency may not conduct or sponsor an information
collection and a person is not required to respond to a
collection of information unless it displays a currently valid
OMB control number. The public reporting burden for this
collection of information is estimated at 12 minutes per
response, including the time for reviewing instructions and
completing and submitting the form. Send comments
regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing
this burden, to: U.S. Citizenship and Immigration Services,
Regulatory Management Division, 111 Massachusetts
Avenue, N.W., 3rd Floor, Suite 3008, Washington, DC
20529-2210. OMB No. 1615-0047. Do not mail your
completed Form I-9 to this address.
Form I-9 (Rev. 02/02/09) N Page 3
OMB No. 1615-0047; Expires 06/30/09
Read instructions carefully before completing this form. The instructions must be available during completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT
specify which document(s) they will accept from an employee. The refusal to hire an individual because the documents have a
future expiration date may also constitute illegal discrimination.
Section 1. Employee Information and Verification (To be completed and signed by employee at the time employment begins.)
Print Name:
Last
First
Pflugenhaven
Middle Initial Maiden Name
W
Otto
Address (Street Name and Number)
Apt. #
Date of Birth (month/day/year)
Zip Code
Social Security #
765 Cornerlot Lane
City
08/09/1989
State
TX
Circle City
78787
123-45-6789
I attest, under penalty of perjury, that I am (check one of the following):
I am aware that federal law provides for
imprisonment and/or fines for false statements or
use of false documents in connection with the
completion of this form.
A citizen of the United States
A noncitizen national of the United States (see instructions)
A lawful permanent resident (Alien #)
E
An alien authorized to work (Alien # or Admission #)
until (expiration date, if applicable - month/day/year)
Employee's Signature
Date (month/day/year)
L
Preparer and/or Translator Certification (To be completed and signed if Section 1 is prepared by a person other than the employee.) I attest, under
penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct.
Print Name
Address (Street Name and Number, City, State, Zip Code)
P
Preparer's/Translator's Signature
M
Section 2. Employer Review and Verification (To be completed and signed by employer. Examine one document from List A OR
examine one document from List B and one from List C, as listed on the reverse of this form, and record the title, number, and
expiration date, if any, of the document(s).)
List A
OR
List B
AND
List C
Social Security Card
Social Security Admin
123-45-6789
Driver's License
State of Texas
01/01/10
A
Document title:
Issuing authority:
Document #:
S
Expiration Date (if any):
Document #:
CERTIFICATION: I attest, under penalty of perjury, that I have examined the document(s) presented by the above-named employee, that
the above-listed document(s) appear to be genuine and to relate to the employee named, that the employee began employment on
and that to the best of my knowledge the employee is authorized to work in the United States. (State
(month/day/year)
employment agencies may omit the date the employee began employment.)
Signature of Employer or Authorized Representative
Print Name
Title
D. Lion
Administrator
Business or Organization Name and Address (Street Name and Number, City, State, Zip Code)
City Zoo, 949 Ninety Four Dr., Circle City, TX 78787
08/08/2008
Section 3. Updating and Reverification (To be completed and signed by employer.)
A. New Name (if applicable)
B. Date of Rehire (month/day/year) (if applicable)
C. If employee's previous grant of work authorization has expired, provide the information below for the document that establishes current employment authorization.
Document Title:
Document #:
l attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented
document(s), the document(s) l have examined appear to be genuine and to relate to the individual.
Form I-9 (Rev. 02/02/09) N Page 4
OMB No. 1615-0047; Expires 06/30/09
Read instructions carefully before completing this form. The instructions must be available during completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT
specify which document(s) they will accept from an employee. The refusal to hire an individual because the documents have a
future expiration date may also constitute illegal discrimination.
Section 1. Employee Information and Verification (To be completed and signed by employee at the time employment begins.)
Print Name:
Last
First
Address (Street Name and Number)
City
State
Apt. #
Date of Birth (month/day/year)
Zip Code
Social Security #
I attest, under penalty of perjury, that I am (check one of the following):
I am aware that federal law provides for
imprisonment and/or fines for false statements or
use of false documents in connection with the
completion of this form.
A citizen of the United States
A noncitizen national of the United States (see instructions)
A lawful permanent resident (Alien #)
An alien authorized to work (Alien # or Admission #)
until (expiration date, if applicable - month/day/year)
Employee's Signature
Preparer and/or Translator Certification (To be completed and signed if Section 1 is prepared by a person other than the employee.) I attest, under
penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct.
Preparer's/Translator's Signature
Print Name
Address (Street Name and Number, City, State, Zip Code)
Section 2. Employer Review and Verification (To be completed and signed by employer. Examine one document from List A OR
examine one document from List B and one from List C, as listed on the reverse of this form, and record the title, number, and
expiration date, if any, of the document(s).)
List A
OR
List B
AND
List C
Document title:
Issuing authority:
Document #:
Document #:
CERTIFICATION: I attest, under penalty of perjury, that I have examined the document(s) presented by the above-named employee, that
the above-listed document(s) appear to be genuine and to relate to the employee named, that the employee began employment on
and that to the best of my knowledge the employee is authorized to work in the United States. (State
(month/day/year)
employment agencies may omit the date the employee began employment.)
Print Name
Business or Organization Name and Address (Street Name and Number, City, State, Zip Code)
Title
Section 3. Updating and Reverification (To be completed and signed by employer.)
A. New Name (if applicable)
B. Date of Rehire (month/day/year) (if applicable)
C. If employee's previous grant of work authorization has expired, provide the information below for the document that establishes current employment authorization.
Document Title:
Document #:
l attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented
document(s), the document(s) l have examined appear to be genuine and to relate to the individual.
Form I-9 (Rev. 02/02/09) N Page 4
LISTS OF ACCEPTABLE DOCUMENTS
All documents must be unexpired
LIST A
LIST B
Documents that Establish Both
Identity and Employment
Authorization
OR
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 machinereadable immigrant visa
4. Employment Authorization Document
that contains a photograph (Form
I-766)
5. In the case of a nonimmigrant alien
authorized to work for a specific
employer incident to status, a foreign
passport with Form I-94 or Form
I-94A bearing the same name as the
passport and containing an
endorsement of the alien's
nonimmigrant status, as long as the
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
nonimmigrant admission under the
Compact of Free Association
Between the United States and the
FSM or RMI
LIST C
Documents that Establish
Employment Authorization
Documents that Establish
Identity
AND
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 a 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
1. Social Security Account Number
card other than one that specifies
on the face that the issuance of the
card does not authorize
employment in the United States
2. Certification of Birth Abroad
issued by the Department of State
(Form FS-545)
3. Certification of Report of Birth
issued by the Department of State
(Form DS-1350)
4. Original or certified copy of birth
certificate issued by a State,
county, municipal authority, or
territory of the United States
bearing an official seal
5. Native American tribal document
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:
10. School record or report card
11. Clinic, doctor, or hospital record
6. U.S. Citizen ID Card (Form I-197)
7. Identification Card for Use of
Resident Citizen in the United
States (Form I-179)
8. Employment authorization
document issued by the
12. Day-care or nursery school record
Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274)
Form I-9 (Rev. 02/02/09) N Page 5
NOTICE TO EMPLOYEES CONCERNING
WORKERS’ COMPENSATION IN TEXAS
COVERAGE: ProSource Management Solutions (and all staff leasing affiliates) has workers’
compensation insurance coverage to protect you in the event of a work-related injury or covered illness.
An employee or a person acting on the employee’s behalf must notify the on-site employer of an injury or
illness no later than the 30th day (i) after the date on which the injury occurs or (ii) the date the employee
knew or should have known of an illness, unless the Division of Workers’ Compensation of the Texas
Department of Insurance determines that good cause existed for failure to provide timely notice. Your onsite
employer is required to provide you with coverage information when you are hired or whenever the onsite
employer becomes, or ceases to be, covered by workers’ compensation insurance.
EMPLOYEE ASSISTANCE: The Division of Workers’ Compensation of the Texas Department of Insurance
provides free information about how to file a workers’ compensation claim. Information regarding your
rights and responsibilities under the Workers’ Compensation Act and assistance in resolving disputes
about a claim can be found at the Division of Workers’ Compensation of the Texas Department of Insurance
website: www.tdi.state.tx.us/wc/indexwc.html or you may contact their Customer Service Department at 1800-252-7031.
SAFETY HOTLINE: The Division of Workers’ Compensation of the Texas Department of Insurance has
established a 24 hour toll-free telephone number for reporting unsafe conditions in the workplace that may violate
health and safety laws. Employers are prohibited by law from suspending, terminating, or discriminating against
any employee because he or she in good faith reports an alleged occupational health or safety violation.
Contact the Division of Workers’ Compensation of the Texas Department of Insurance hot line at 1-800-452-9595.
Employee Acknowledgment of Workers’ Compensation Network
I have received information that tells me how to get health care under my employer’s workers’
compensation insurance if I believe I have been injured or hurt while performing my job.
If I am hurt on the job and live in a service area described in this information, I understand that:
1. I must choose a treating doctor from the list of doctors in the network. Or, I may ask my HMO primary care
physician to agree to serve as my treating doctor. If I select my HMO primary care physician as my treating
doctor, I will call Texas Mutual at (800) 859-5995 extension 2880 to notify them of my choice.
2. I must go to my treating doctor for all health care for my injury. If I need a specialist, my treating doctor will
refer me. If I need emergency care, I may go anywhere.
3. The insurance carrier will pay the treating doctor and other network providers.
4. I might have to pay the bill if I get health care from someone other than a network doctor
without
network approval.
5. Making a false or fraudulent workers’ compensation claim is a crime that may result in fines
and or
imprisonment.
Employee’s Signature __________________________________________Date ______________________
Printed Employee’s Name _______________________________________________
I live at Address (Number & Street) ______________________________________________________________
City, State & Zip _______________________________________________________
Name of Employer _____________________________________________________
Name of Network: Texas Star Network
Network service areas are subject to change. Call (800) 381-8067 if you need a network treating provider.
1502 Augusta Drive • Suite 100 •Houston, TX 77057 • 1‐888‐667‐3690 Employment Dispute Resolution Statement
By completing and submitting this Resolution, I understand and agree:
To comply with the ProSource Management Solutions’ Employment Dispute Resolution
Policy and Procedure, including resolving any, very, each and all employment claims,
disputes, and/or controversies now existing or hereafter arising, through exclusive use of
final and binding arbitration conducted solely by the American Arbitration Association.
This agreement regarding dispute resolution is the only required and exclusive way for all
applicants, employees, former employees, employers and ProSource Management
Solutions (and affiliates) to resolve any, every, each and all employment claims, disputes,
and/or controversies whether known or unknown. All arbitrations shall be exclusively
pursuant to the provisions and jurisprudence interpreting, of the Federal Arbitration Act.
ACCEPTED AND AGREED TO:
Employee’s Signature _________________________________ Date ________________
Printed Employee’s Name __________________________________
Social Security Number ____________________
1502 Augusta Drive • Suite 100 •Houston, TX 77057 • 1‐888‐667‐3690 EMPLOYMENT AGREEMENT
EXHIBIT “C”
This agreement is made between ProSource Management Solutions (“ProSource”) in conjunction with _________________
“the Client Company”, (“Employer”) and ____________________________________(“Employee”).
I.
DUTIES OF EMPLOYMENT
1.1 Employee is hereby employed as a ______________________________________________ and is to be
supervised during his term of employment by ________________________________________ (the “Client Company”).
Employee agrees to perform such duties as shall be determined from time to time by the Client Company, the Employer.
Employee understands that additional duties may be assigned from time to time by the Employer. All duties will be promptly
communicated to the Employee by an on-site supervisor employed by the Client Company, the employer.
1.2 The duties of Employee may be changed from time to time by the Employer. Notwithstanding any such changes, the
employment of Employee shall be construed as continuing under this Agreement, as modified.
II.
GENERAL PROVISIONS
2.1. At Will Employment. In consideration of employment, Employee agrees to conform to the policies and rules of
ProSource and Client Company. Employee further agrees that his/her employment and compensation can be terminated, with
or without cause and without notice, at any time, at the option of either the Employer or Employee. Employee understands no
onsite supervisor or representative of Employer, other than the CEO of Client Company and/or his/her designee, (and then
provided in writing to ProSource), has authority to enter into an agreement for employment for any specific period of
time, or to make any agreement contrary to the foregoing and as stipulated by policies and rules established by
ProSource and the Client Company.
2.2 Current Agreement. This Agreement supersedes any and all other agreements, either oral or in writing, between
the parties hereto with respect to the Employees employment by ProSource and the client Company and contains the basic
covenants and agreements between the parties with respect to such employment. Employee understands this agreement
does not contain all rules, regulations or policies of ProSource and the Client Company and Employee agrees to read and
understand all such rules, regulations and/or policies.
2.3 Governing Law. This Agreement shall be governed by and construed in accordance with the law of the State of
Texas.
NOTICE: Questions and unresolved complaints concerning staff leasing services should be directed to the Department of
Licensing and Regulation, P. O. Box 12157, Austin, TX 78711, (800) 803-9202.
2.4 Notices. All notices, requests and communications with regard to employment shall be in writing, mailed by United
States First Class Mail. Notices to the Employer must be sent to the address given below. Notices to the Employee must be
sent to the most recent address on record with the Employer.
2.5 Waiver. The waiver by either party hereto of a breach of any term or provision of this Agreement shall not operate
or be construed as a waiver of a subsequent breach of the same provision or of a breach of any other term or provision of this
Agreement.
2.6 Claim/Lawsuit Waiver. I agree that any claim or lawsuit relating to my term of service with ProSource/
___________________________________ (Client Company) or any of its affiliates or subsidiaries must be filed no more than
six (6) months after the date of employment action that is the subject of the claim or lawsuit. I waive any statute of limitations
to the contrary.
Employee’s Signature ____________________________________________
Printed Employee’s Name _________________________________________
Social Security Number _______________________
Signed on This Date______________
PROSOURCE MANAGEMENT SOLUTIONS BY: ____________________________________
1502 Augusta Drive • Suite 100 •Houston, TX 77057 • 1‐888‐667‐3690 BENEFIT ELECTION FORM
Print Employee Name _________________________________Social Security # _________________
Section 1) BENEFIT ELECTION
PROCEDURE FOR PAYMENT OF INSURANCE PREMIUMS(S) UPON TERMINATION OF
EMPLOYMENT: If your employment is voluntarily or involuntarily terminated and the monthly
insurance premium(s) or any portion of the monthly insurance premium(s) is paid by the employee
through regular payroll deductions, the total outstanding premium amount(s) due for the month in
which your employment was terminated will be deducted from your final paycheck.
I HAVE REQUESTED MEDICAL COVERAGE AND AGREE TO PAY MY PORTION OF THE MEDICAL
PREMIUM IF APPLICABLE. I understand and agree to the aforementioned procedure regarding
payment of insurance premium(s) due upon termination of employment with ProSource Management
Solutions.
Employee Signature _______________________________________ Date______________________
Section 2) Waiver (as applicable, if applicable)
I waive medical coverage for:
_________ Myself & dependents
_________ Spouse
_________ Children
Please state reason for waiving coverage: __________________________________________________
____________________________________________________________________________________
If covered by another plan, name of the plan: ________________________________________________
____________________________________________________________________________________
Employee Signature ________________________________________ Date ____________________
Section 3) PAYROLL DEDUCTIONS
I UNDERSTAND THAT ANY ADDITIONAL PAYROLL DEDUCTIONS SUCH AS PAYMENT FOR
UNIFORMS, PAGERS, OR THE REPAYMENT OF PAYROLL ADVANCES (IF APPLICABLE),
MISCELLANEOUS ITEMS, ETC., WILL REQUIRE ME TO SIGN A SPECIFIC PAYROLL DEDUCTION
FORM. BY SIGNING THE REFERENCED DEDUCTION FORM I AUTHORIZE THE DEDUCTION
AND AGREE TO THE TERMS AS STATED IN THE SPECIFIC DEDUCTION FORM.
Employee Signature__________________________________________ Date____________________
1502 Augusta Drive • Suite 100 •Houston, TX 77057 • 1‐888‐667‐3690 PAYROLL DEDUCTION FORM
NOTICE TO EMPLOYER:
A “PAYROLL DEDUCTION FORM” is required to allow the
Employer/ProSource to deduct funds from the pay of an Employee. A deduction form is required to
be signed by all Employees purchasing or assigned uniforms, Employees provided a pager or cell
phone, and those that must place a deposit for the use of the Employer’s uniform or property.
Additionally, all employees should sign a Deduction Form to allow the Employer/ProSource to
deduct funds owed the Client Employer due to an advance or otherwise, upon the Employee’s
conclusion of the work assignment.
PAYROLL DEDUCTIONS:
I ______________________________________________ (Employee Name) authorize ProSource Management
Solutions to deduct funds as calculated below for the purpose specified:
DEDUCTION APPLICATION:
(Please check and place amount in the blank next to deposit/purchase where and when applicable)
#
ITEM
AMOUNT
TYPE OF DEDUCTION
______
Pager
________
Deposit (refundable upon return of Pager)
______
Cell Phone
________
Deposit (refundable upon return of Cell Phone)
______
Uniform(s)
________
Set-up Fee (non-refundable)
______
Uniform(s)
________
Deposit (refundable upon return of Uniform)
______
Uniform(s)
________
Purchase (non-refundable)
______
Uniform Expense
________
CLEANING (non-refundable)
______
*Other
________
Employee Advance/Loan or other funds due.
*List “Other” Item(s) below (be specific and descriptive):
____________________________ Refundable
____________________________Non-Refundable
____________________________ Refundable
____________________________Non-Refundable
____________________________ Refundable
____________________________Non-Refundable
WHEN APPLICABLE DEDUCTION CALCULATION:
$ _____________per paycheck x ________ number of paychecks = __________total deduction amount
I, ____________________________________ understand upon the conclusion of my work assignment, it is my
responsibility to return all property as listed above or otherwise, to __________________________________the
Client/Employer. Failure to return any item listed or unlisted that is the property of the Company, or failure to pay
an advance or loan, or other funds due the Employer, will result in a forfeiture of funds equal to the value of the
item(s) not returned or the balance of funds owed. Upon receipt of verification that all items have been returned or
that all advances or loans of funds due have been repaid, ProSource Management Solutions will issue a check
for any amount due the Employee. When possible, any applicable reimbursement will be reflected on the final
check. If the funds are not paid or reimbursed with the final check, any funds due an Employee because of the
above stated process will be paid to the Employee within two weeks of conclusion of the work assignment.
Employee Signature _________________________________ Date ___________________
Employer Signature _________________________________ Date ___________________
1502 Augusta Drive • Suite 100 •Houston, TX 77057 • 1‐888‐667‐3690 Please attach check or checks here.
AGREEMENT FOR PRE-AUTHORIZED PAYMENTS
DEBIT/CREDIT
PROSOURCE MANAGEMENT SOLUTIONS (ProSource) is a Professional Employer Organization, also known as a Staff
Leasing Company. The Customer (or Client) or Employee of ProSource hereby authorizes and allows ProSource to
initiate debit/credit entries, directed to a Receiving Financial Institution, authorizing the receiving financial institution
to accept the debit/credit and to post the entries to a specified account for the benefit of ProSource. This
agreement contains and authorizes the following:
1)
2)
3)
4)
5)
6)
7)
Authorization for PROSOURCE to initiate debit/credit entries and for the Receiving Financial Institution to
accept the debit/credit entries.
Authorization for the customer/client/employee to terminate the agreement in writing.
Customer/Client/Employee Name.
Receiving Financial Institutions transit/routing number
Customer/Client/Employee account number at Receiving Financial Institution.
Customer/Client/Employee signature and date signed.
Customer/Client/Employee authorizes ProSource to initiate the referenced debit/credit transaction and to
direct that the funds be forwarded to a Financial Institution as designated by ProSource.
AUTHORIZATION AGREEMENT FOR AUTOMATIC DEPOSIT/DEBIT
PROSOURCE MANAGEMENT SOLUTIONS is authorized to initiate credit/debit entries and to initiate, as and when
necessary, debit entries and adjustments of credit entries, to the following account(s):
nd
________ Checking Account ________ 2 Account (if applicable) - at the financial institution hereinafter indicated
(the “Receiving Financial Institution” of Customer/Client/Employee), to credit and/or debit the entry to such account.
Customer/Client/Employee’s
BANK’S NAME ____________________________________
CITY, STATE, ZIP ___________________________________
TRANSIT/ABA# ___________________________________
ACCOUNT # ______________________________________
This authority remains in effect until PROSOURCE has received ten (10) day advanced written notification from the
undersigned terminating this Debit/Credit Agreement. Once the employment relationship is terminated by any party, the last
and final payment will be by paper check.
Signature _____________________________________
Signed on This Date ____________
Printed Employee’s Name _________________________ Social Security # _______________
BANK’S NAME ____________________________________
CITY, STATE, ZIP ___________________________________
TRANSIT/ABA# ___________________________________
ACCOUNT # ______________________________________
This authority remains in effect until PROSOURCE has received ten (10) day advanced written notification from the
undersigned terminating this Debit/Credit Agreement. Once the employment relationship is terminated by any party, the last
and final payment will be by paper check.
Signature _____________________________________
Signed on This Date ____________
Printed Employee’s Name _________________________ Social Security # _______________
1502 Augusta Drive • Suite 100 •Houston, TX 77057 • 1‐888‐667‐3690 Employee Acknowledgment Form
I have received THE “PLAIN LANGUAGE” HANDBOOK and understand and acknowledge this
employee handbook describes important information about ProSource Management
Solutions and the Client company and the relationship between ProSource and the Client
company. I understand that I should consult the on site Manager or a ProSource
representative regarding any question raised or not answered in the handbook.
Since the information, policies, and benefits described therein are necessarily subject to
change, I acknowledge that revisions to the handbook may occur. All such changes will be
communicated through official notices, and I understand that revised information may
supersede, modify, or eliminate existing policies. Only the Directors of ProSource Management
Solutions have the ability to adopt any revisions to the policies in this handbook.
Furthermore, I acknowledge that this handbook is neither a contract of employment nor a
legal document, and that my employment is an at will relationship and not contractual. I have
received the handbook, and I understand that it is my responsibility to read and comply with the
policies contained in this handbook as well as any and all documents provided by ProSource
and those of the Client company, and any revisions made to them.
As an employee of the Client Company/ProSource Management Solutions, I have read the
RULES OF CONDUCT, and understand the handbook and each of the above items of
unacceptable conduct.
I also understand that violation of any of the above items may be considered grounds for
disciplinary action up to and including termination of my employment.
I understand that by signing below I acknowledge that I am in receipt of the combined
ProSource Management Solutions Employee “Plain” Language Handbook and RULES OF
CONDUCT, and that I agree to comply with the policies and procedures as stated in the
Employee “Plain” Language Handbook and will comply with the RULES OF CONDUCT.
Employee Signature ___________________________________ Date ___________________
1502 Augusta Drive • Suite 100 •Houston, TX 77057 • 1‐888‐667‐3690 Investigation Consent Form and Receipt of Summary of FCRA Rights
I understand and acknowledge that an investigative consumer report may be obtained for employment purposes. I authorize the
company I have made application with, or its designated agent, to conduct pre-employment or other employment related inquiries
after I am hired (to the extent allowed by law) and authorize any past or present employer, or other business, governmental agency
or individual contacted to supply the requested information and documents concerning me and to provide full and complete
disclosure. I understand that all pre-employment screening activities are conducted in compliance with ADA, EEOC and the Fair
Credit Reporting Act (FCRA) requirements. I release from liability the company I have made application with, and its
representatives for gathering and using such information. I fully release the person or entity providing the information of any right or
claim of confidentiality concerning disclosure of the information requested below or any and all claims, actions, or causes of action
which may arise as a consequence of the release of such information as may be requested concerning: (1) Complete background
reference and work history checks; (2) Criminal and civil litigation history information or any other public records (such as driving
records, liens, judgments, and sex offender status); (3) Credit reports, academic achievement, professional licensure, bankruptcy
filings; (4) Previous incidents of alleged sexual or racial harassment; (5) Previous incidents of violent behavior and/or suspected
dishonest acts; (6) Results of previous drug testing within the past two years if positive for illegal substances; (7) Eligibility for rehire
and circumstances of previous separations from employment; (8) Social Security Number verification; and (9) information
concerning any or all worker’s compensation claims if a conditional offer of employment has been made. I request that any law
enforcement agency, institution, information service bureau, school, employer, reference, or insurance company contacted
pursuant to this investigation consent form cooperate fully and completely in responding to the inquiries. By my signature below,
I acknowledge that I have received a Summary of my Rights under the Fair Credit Reporting Act (FCRA).
________________________________________________
Signature
______________________
Date
APPLICANT INFORMATION:
________________________________________
Last Name
________________________________
First Name
__________ __________
________________________________________
Home Address
________________________________
City
_______________________
State
Zip Code
________________________________________
Former Address
________________________________
City
_______________________
State
Zip Code
_____________________________
Social Security Number
_____________
Date of Birth
_____________________
Drivers License Number
_____________________
State License Issued
EMPLOYER INFORMATION:
CHARLOTTE INGRAM
Requestor’s Name
(713) 667-3690
Phone Number
PROSOURCE MANAGEMENT SOLUTIONS
Company Name
(713) 660-9629
Fax Number
Company Code
SERVICES ORDERED:
Criminal History
PEER Credit Report
Motor Vehicle Report
Education Verification
Employment Verification
Trace/SSN Check
National Crim Search
State Sex Offender Search
National Sex Offender Search
Professional License Check
OIG Check
Reference Verification
Drug Screening
Fingerprinting
Credit Report (Tenant)
Mail Only
Call Before Fax
Website
Email
RETURN RESULTS BY:
Fax Only
Verbal Only
Verbal & Fax
1630 29th Court South ٠ Birmingham, Alabama 35209 tel (205) 879-0143 fax (205) 380-7548 toll free (866) 859-0143
A Summary of Your Rights Under the Fair Credit Reporting Act
The federal Fair Credit Reporting Act (FCRA) is designed
to promote accuracy, fairness, and privacy of information in
the files of every “consumer reporting agency” (CRA).
Most CRAs are credit bureaus that gather and sell
information about you - such as if you pay your bills on time
or have filed bankruptcy - to creditors, employers,
landlords, and other businesses. You can find the complete
text of the FCRA, 15 U.S.C. 1681-1681u, at the Federal
Trade Commission’s web site (http://www.ftc.gov). The
FCRA gives you specific rights, as outlined below. You may
have additional rights under state law. You may contact a
state or local consumer protection agency or a state attorney
general to learn those rights.
• You must be told if information in your file has been used
against you. Anyone who uses information from a CRA to
take action against you - such as denying an application for
credit, insurance, or employment - must tell you, and give
you the name, address, and phone number of the CRA that
provided the consumer report.
• You can find out what is in your file. At your request, a
CRA must give you the information in your file, and a list
of everyone who has requested it recently. There is no
charge for the report if a person has taken action against you
because of information supplied by the CRA, if you request
the report within 60 days of receiving notice of the action.
You also are entitled to one free report every twelve months
upon request if you certify that (1) you are unemployed and
plan to seek employment within 60 days, (2) you are on
welfare, or (3) your report is inaccurate due to fraud.
Otherwise, a CRA may charge you up to eight dollars.
• You can dispute inaccurate information with the CRA. If
you tell a CRA that your file contains inaccurate
information, the CRA must investigate the items (usually
within 30 days) by presenting to its information source all
relevant evidence you submit, unless your dispute is
frivolous. The source must review your evidence and report
its findings to the CRA. (The source also must advise
national CRAs - to which it has provided the data - of any
error.) The CRA must give you a written report of the
investigation, and a copy of your report if the investigation
results in any change. If the CRA’s investigation does not
resolve the dispute, you may add a brief statement to your
file. The CRA must normally include a summary of your
statement in future reports. If an item is deleted or a dispute
statement is filed, you may ask that anyone who has recently
received your report be notified of the change.
• Inaccurate information must be corrected or deleted. A
CRA must remove or correct inaccurate or unverified
information from its files, usually within 30 days after you
dispute it. However, the CRA is not required to remove
accurate data from your file unless it is outdated (as
described below) or cannot be verified. If your dispute
results in any change to your report, the CRA cannot reinsert
into your file a disputed item unless the information source
verifies its accuracy and completeness. In addition, the CRA
must give you a written notice telling you it has reinserted
the item. The notice must include the name, address and
phone number of the information source.
• You can dispute inaccurate items with the source of the
information. If you tell anyone - such as a creditor who
reports to a CRA - that you dispute an item, they may not
then report the information to a CRA without including a
notice of your dispute. In addition, once you’ve notified the
source of the error in writing, it may not continue to report
the information if it is, in fact, an error.
• Outdated information may not be reported. In most cases,
a CRA may not report negative information that is more
than seven years old; ten years for bankruptcies.
• Access to your file is limited. A CRA may provide
information about you only to people with a need recognized
by the FCRA — usually to consider an application with a
creditor, insurer, employer, landlord, or other business.
• Your consent is required for reports that are provided to
employers, or reports that contain medical information. A
CRA may not give out information about you to your
employer, or prospective employer, without your written
consent. A CRA may not report medical information about
you to creditors, insurers, or employers without your
permission.
• You may choose to exclude your name from CRA lists for
unsolicited credit and insurance offers. Creditors and
insurers may use file information as the basis for sending
you unsolicited offers of credit or insurance. Such offers
must include a toll-free phone number for you to call if you
want your name and address removed from future lists. If
you call, you must be kept off the lists for two years. If you
request, complete, and return the CRA form provided for
this purpose, you must be taken off the lists indefinitely.
• You may seek damages from violators. If a CRA, a user
or (in some cases) a provider of CRA data, violates the
FCRA, you may sue them in state or federal court.
The FCRA gives several different federal agencies authority to enforce the FCRA:
For Questions or
Concerns Regarding:
Please Contact:
CRAs, creditors and others not
Federal Trade Commission
listed below
Bureau of Consumer Protection FCRA
Washington, DC 20580 202-326-3761
National banks, federal branches/
Office of the Comptroller of the Currency
agencies of foreign banks (word
Compliance Management, MS 6-6
“National” or initials “N.A.” appear Washington, DC 20219 800-613-6743
in or after bank’s name)
Federal Reserve System member
Federal Reserve Board
banks (except national banks, and
Consumer & Community Affairs
federal branches/agencies of
Washington, DC 20551
202-452-3693
foreign banks)
Savings associations and federally
Office of Thrift Supervision
chartered savings banks (word
Consumer Programs
“Federal” or initials “F.S.B.” appear Washington, DC 20552 800-842-6929
in federal institution’s name)
Federal credit unions (words
National Credit Union Administration
“Federal Credit Union” appear in
1775 Duke Street
institution’s name)
Alexandria, VA 22314 703-518-6360
Banks that are state-chartered or
Federal Deposit Insurance Corporation
are not Federal Reserve System
Compliance & Consumer Affairs
members
Washington, DC 20429 800-934-FDIC
Air, surface or rail common carriers Department of Transportation
regulated by former Civil Aeronautics Office of Financial Management
Board or Interstate Commerce
Washington, DC 20590 202-366-1306
Commission
Activities subject to the Packers
Department of Agriculture
and Stockyards Act, 1921
Office of Deputy Administrator-GIPSA
Washington, DC 20205 202-720-7051
Employee “Plain” Language Handbook
and
RULES OF CONDUCT
THE “PLAIN LANGUAGE” HANDBOOK
ProSource Management Solutions (ProSource), licensed by the State of Texas, is a Professional
Employee Organization, commonly known as an “employee leasing” company.
ProSource signs an
agreement with the employer, the Client Company. As a result of the agreement, ProSource
administers, for the employer, including, but limited to, payroll, employee benefits, and personnel affairs
(sometimes referred to as “human resources”).
Every successful business states, for all to understand, the policies employees are expected to value and
follow. This “Plain Language” Handbook sets out, in general terms, the policies of ProSource and of the
Client Company. It is important that you know and understand the policies, which allows you to comply
with and to support them.
This handbook includes a number of policy statements, but is not complete in stating all company
policies. Nevertheless, it is your responsibility to take the time to read the handbook and direct any
questions to your on-site supervisor or a representative of ProSource. This handbook is for your
information and is not a legal document or an employment contract. Without regard to the foregoing
statement, it is your responsibility to abide by the policy statement(s) and the Rules of Conduct
stated herein.
EQUAL OPPORTUNITY EMPLOYMENT
ProSource and the Client Company provide equal opportunity employment without regard to race, color, religion,
national origin, ancestry, gender, age, disability, or military status. ProSource will maintain a work environment free
of prejudice, racial bias, and any form of harassment, sexual or otherwise. It is your responsibility to report any
noticed violation in this regard.
EMPLOYMENT
ProSource supports its Client Companies in efforts to recruit and hire employees who have the technical
skills and experience required for authorized employment positions. Employment references of all
applicants are checked. Any misrepresentations, falsifications or material omissions of information or
data may result in the exclusion of an individual from further consideration for employment, or, if the
person has been hired, termination of employment.
LICENSE, REGISTRATION AND CERTIFICATION VERIFICATION
ProSource and its Client Companies will verify, as necessary, that all professional and technical
personnel have valid and current license, registration and/or certification commensurate with position
requirements.
PROSOURCE, ITS CLIENTS AND SAFETY
ProSource, through the fostering and promotion of a safety program, supports its Client Companies in the
Client Company’s attempt to provide an environment free of physical and environmental hazards for its
employees while also striving to protect the safety and welfare of Client customers, patrons, visitors and
employees. In keeping with the intent of various regulatory agencies, ProSource and its Client
Companies recognize safety as an important component of quality.
Employees are required to operate safely, following all polices and guidelines of ProSource and the Client
Company, and wear all protective equipment required for their position.
ProSource and its Client Companies carry Workers’ Compensation Insurance to protect qualified
employees injured on the job.
SUBSTANCE ABUSE
ProSource and its Client Companies are committed to maintaining safe, productive working conditions.
Employees who are under the influence of drugs or alcohol pose a serious threat to the health and safety
of themselves, other employees, customers, clients or patrons, as well as anyone who comes into contact
with them. The manufacture, distribution, use, possession or sale of drugs or alcohol in the workplace or
while at work creates unacceptable risks to safety and efficiency. ProSource requires random, postaccident and/or “for cause” drug testing. Refusal of test will be considered a voluntary resignation
of employment and may disqualify an employee from receiving unemployment benefits. This policy
applies to all employees while performing ProSource or Client Company business or while on or in
ProSource or Client Company property. This policy also applies to all applicants for employment.
Revised 2/08
2
ATTENDANCE AND PUNCTUALITY
All employees are expected to report to work on time and when scheduled. While Client Company, and
ProSource will discuss specific policies with the employees, absence of three (3) consecutive work
days without notifying the Employer will be considered voluntary resignation due to job abandonment.
UNACCEPTABLE JOB PERFORMANCE - VIOLATION OF RULES AND CORRECTIVE ACTION
Employees will be counseled verbally and in writing for unacceptable job performance and/or violation of
ProSource and Client Company rules.
If a corrective action plan is not followed and if satisfactory
improvement is not exhibited within an acceptable stated time frame, further action will be taken, up to
and including discharge.
As stated hereinafter in the Rules of Conduct, which are incorporated herein by reference, some major
offenses can justify immediate discharge, without regard to prior conduct.
Position Elimination/Conclusion
ProSources’ Client Companies will make every effort to provide steady employment. However, should
circumstances cause the elimination of a position, the employee should contact the ProSource office to
determine if other work is available at another ProSource Client Company. Under Section 207.045(I) of
the Texas Unemployment Compensation Act a severed employee must contact ProSource Management
Solutions by the end of the next business day to report his or her availability for reassignment. Failure to
follow this policy could jeopardize the possibility of such employee receiving unemployment benefits.
CONFIDENTIALITY
It is the responsibility of all employees to safeguard sensitive company information. The protection of confidential
business or trade secrets is vital to the interest and success of the Client Company. I agree to comply with this stated
policy.
Such information includes, but is not limited to, the following examples: Patron’s lists and names,
information related to Client’s patrons/clients, financial information, including employee salaries, labor relations
strategies, marketing strategies, pending projects, price lists, supplies’ names, discounts or terms, billing rates
charged.
ProSource, it’s Client Companies, and all customers/patrons/clients expect employees to be ethical in
handling all confidential information. Employee shall not discuss the Client Company’s or a
customer’s/patron’s/client’s information with others.
Doing so shall require disciplinary action, up to and
including termination. Once hired, (1) the signing of the APPLICATION FOR EMPLOYMENT SHORT FORM
(and allied documents) and (2) the acceptance of employment, is evidence of your agreement not to disclose
confidential information, including, but not limited to, the information above listed. Employees who improperly
use or disclose trade secrets or confidential business information will be subject to disciplinary action, up to
and including termination of employment and other action as necessary, even if the employee does not
actually benefit from the disclosed information. Upon termination, I agree not to disclose, for a 12 month
period, confidential, proprietary information, or trade secrets, which were learned while I was employed.
Further, I understand that to reveal confidential, proprietary information, or trade secrets may subject me to legal
action, including injunction proceedings, and I hereby consent to the order of an immediate injunction, without bond,
from any court of competent jurisdiction, enjoining and restraining me from violating or threatening to violate this
provision.
EMPLOYMENT CLASSIFICATIONS
Each employee is designated as either Non-exempt or Exempt from “federal and state wage and hour
laws”. Non-exempt employees are entitled to overtime pay under specific provisions of federal and state
laws. Exempt employees are excluded from specific provisions of federal and state wage and hour laws. An
employee’s Non-exempt or Exempt classification may be changed only upon written notification by
management of Client Company with ProSource approval.
In addition, employees are classified as:
Full time (30 hours or more each week on a regular basis)
Part time (less than 30 hours each week on a regular basis)
Supplemental (No ongoing scheduled work time, but are asked to work on an as-needed basis)
Revised 2/08
3
Per Diem (Intermittently scheduled by the shift, as needed, and/or on extra shifts.)
NOTE: Other classifications may exist with various Client Companies.
90 DAY PROBATIONARY EMPLOYMENT
Most Client Companies’ supervisors will complete, prior to the expiration of the first 90 days of
employment (unless otherwise stated in the job adjustment period of the position description) a written
performance appraisal to provide new employees with feedback as to how well they are performing. It is
important that employees know and understand what is expected as “work performance and work
behavior”, and whether or not they are meeting and/or exceeding those expectations. If you have not
received an appraisal, you may request one from your immediate supervisor.
It is within Client Company’s determination as to whether a pay increase is warranted for new employees
based on performance after completion of the first 90 days of employment. Within the same period, if it is
determined that the employee’s performance, skills and/or attitude is not acceptable, it is possible that
employment may be terminated.
WAGE ADMINISTRATION
Although ProSource assists its Client Companies in surveying and analyzing wages to ensure equitable
wages in accordance with the prevailing wage scale within your specific labor market, Client Companies
are ultimately responsible for designating wages for each position.
WORK HOURS, PAY DAYS & PAYCHECKS
Work-hours and work-weeks are determined by the Client Company. Employees will receive from their
Client Company manager/supervisor specific information regarding when the work-week begins and ends as
well as scheduled work hours.
Paydays are determined by the Client Company in accordance with standard rules and regulations.
Employees will be informed by the Client Company as to scheduled paydays. Paychecks are not issued to
employees in advance of scheduled paydays, unless the employee is not scheduled to work on a payday.
In such cases, if paychecks are available, the supervisor may distribute a check on the last day worked
prior to pay-day.
A paycheck will not be released to anyone other than the employee for whom it is intended without written
authorization from the employee.
A Texas driver’s license or similar picture I.D. will be required for
release of an employee paycheck.
ProSource shall not honor assigning of an employee’s paycheck for payment of debt unless required by
law.
Once an employment relationship is terminated by the employee or the employer, the last and final pay to be
received will be by check.
RECORDING HOURS WORKED
Depending on procedure, either time clocks or sign-in sheets are used to record work hours at each
Client Company. These records are the basis for computing pay. Employees are required to clock-in or
sign-in for each pay period and must do so immediately upon reporting to work. Each employee must
clock-out or sign-out when leaving work. Recording of work time is to be performed only by the employee for
whom the time is being reported.
Recording worked time for another employee subjects both
employees to discharge. Any alterations or notations on time cards or time sheets must be initialed by the
employee’s supervisor/manager.
All employees must initial their time card or time sheet at the end of the last shift worked each workweek.
PAY INCREASES
Merit pay increases are based on individual job performance as documented by an employee’s
performance appraisal. A pay raise will become effective on the next scheduled pay period.
PERFORMANCE APPRAISALS (AT CLIENT COMPANY’S OPTION)
Job performance appraisals at scheduled intervals are opportunities for employees to receive feedback
from their supervisor/manager regarding their job performance. Regular discussions of goals and job
performances are strongly encouraged at each client company.
Revised 2/08
4
Job performance appraisals are generally performed prior to completion of the first
90 days of
employment without a pay merit increase, unless otherwise determined by the Client Company.
Thereafter, job performance will generally be formally appraised on an employee’s annual anniversary
date.
The job appraisal is used to identify areas of growth, development and concerns and will serve as a basis for
merit pay increases. Job performance appraisals are part of an employee’s permanent file.
Paid Time Off, Holidays, Personal Days, Sick Time, Jury Duty, Bereavement Leave, Military Leave
The above referenced policy(s) will differ from company to company. Client Companies are responsible for
determining the policies for all above listed days. The manager/supervisor of the Client Company will
discuss the policy with all employees.
FAMILY AND MEDICAL LEAVE (FAMILY and MEDICAL LEAVE APPLIES ONLY TO CLIENT COMPANIES
WITH 50 OR MORE EMPLOYEES)
If applicable, ProSource and Client Company provides up to 12 weeks of unpaid, job-protected leave
during each payroll year to an employee who has been employed with a Client Company for at least one
year and has worked for ProSource/Client Company at least 1250 hours over the previous 12 months,
and if there are at least 50 Client Company employees within 75 miles. The employee may request a
Family or Medical Leave for one or more of the following reasons:
*To care for employee’s child after birth, or placement for adoption or foster care-care, within 12 months of
placement.
*To care for the employee’s spouse, child (under age 18 or disabled) or parent, who has a certified
serious health condition; or
*The employee’s certified serious health condition, which may require 2nd or 3rd opinions.
The employee may be required to supply advanced leave notice, usually 30 days. Leave may be denied if
requirements are not met.
The employee, if covered during employment prior to FMLA leave, must maintain health coverage under
any “group medical plan”, without Employer’s contribution.
A “serious health condition” may involve inpatient care in a hospital, hospice or residential medical facility, or
continuing treatment by a health care provider.
Leave may be granted for continuing treatment or a period of incapacity or a serious health condition due to
pregnancy.
Employees are required to provide supervisor/manager with certification from a health care provider. All
certifications must be updated each 30 days.
If two certification opinions differ, ProSource or Client
Company will submit a list of health care providers to secure an independent opinion to resolve the
issue.
If both spouses are employed by Client Company, they are jointly entitled to a combined total of twelve
weeks of unpaid leave, except for the spouse or child with a serious health condition.
If the leave is for planned medical treatment or to be taken on an intermittent basis or by a reduced
schedule, the employee is expected to schedule the treatment so as to create minimum disruption for
Client Company. Employees are required to use any accrued time-off as part or all of their 12 week leave
period, with any balance of time granted as unpaid leave.
Employees who return to work immediately upon expiration of leave will return to the same or an
equivalent position. An “equivalent position” is one with the same pay, benefits, and working conditions in the
same geographical area with the same or equivalent schedule. Employees returning from his or her medical
leave must provide a physician’s release.
CREDIT UNION
ProSource is affiliated with the Memorial Hermann Credit Union, a cooperative, nonprofit institution
created to encourage thrift and provide a source of credit at fair and reasonable interest rates to all its
members. All employees are eligible for membership. Credit Union membership is also available to family
members who wish to establish an account. Payroll deduction options are available for employees to
make routine deposits into their credit union account.
Memorial Hermann Credit Union is located on the concourse level of Memorial Hermann Southwest
(Professional Office Building I) in Suite C-10 but has service centers located in the Houston area and is
Revised 2/08
5
affiliated with a network of credit unions throughout the state of Texas.
number is (713) 456-5300.
The credit union’s telephone
GROUP MEDICAL INSURANCE
Medical Insurance options are available to employees if the Client Company participates in a group
medical plan. If a participant, each employee will be informed by the Client Company as to the dollar
amount each employee will be responsible to pay toward his or her group medical coverage.
Each
participating Client Company will provide more information.
401K SAVINGS PLAN
A 401k Savings Plan will be available to employees if the Client Company participates in the ProSource
401k Profit Sharing Plan or if the Client Company has its own individual 401k Plan. More information will be
provided to employees if the Client Company participants in either option.
CAFETERIA 125 SAVINGS PLAN
All employees are eligible to participate in a premium-only Cafeteria 125 Savings Plan with the assistance of
the FlexOne Program. This allows employees to use pre-tax salary dollars through payroll deduction to pay
for selected benefits.
OTHER OPTIONS…
Optional supplemental insurance programs are available to employees at a cost.
A benefits
representative is available should an employee have interest in other such programs. The ProSource
Benefits Department will respond to questions in this regard.
RETURN OF PROPERTY OR FUNDS OF COMPANY
Employees are responsible for all equipment, property, materials, or written information issued to them by
the Company that is in the employee’s possession or control. Employees must return all Company and/or
ProSource property immediately upon request, when the job for which the equipment (or other issued
items) was issued is completed, or upon termination of employment. The Company/ProSource may take
all action deemed appropriate and permitted by applicable law to recover or protect its property. If the
Company has issued property, including, but not limited to, a pager, cell phone, uniform, or if the
Company has spent funds in any capacity for the Employee, or if the Company has advanced funds to an
Employee, the Employee authorizes recovering any cost associated with the issued property or funds
spent or advanced, from the last pay check. Upon termination, I understand the signing of the Employee
Acknowledgement Form attached hereto authorizes, and I hereby consent to the Company/ProSource
deducting from my last pay check, or if notice of termination has been given in advance, from any and all
paychecks, the funds necessary for the Company to be properly reimbursed in this regard.
DISPUTE RESOLUTION PROCEDURE
Misunderstandings or conflicts can arise in any organization. To ensure effective working relations, it is
important that such matters be resolved before serious problems develop. Most incidents resolve
themselves naturally; however, should a situation persist that you believe is detrimental to your
employment you should follow the Client Company’s procedure to bring your complaint to the Client
Company’s attention. You should request of your immediate supervisor or Office Manager the Client
Company’s procedures in this regard.
All employees have read, agreed to and signed the ProSource Dispute Resolution Policy and
Procedure. You have agreed to these procedures as a result of your employment. For clarity, the
procedure(s) specify, and you (I) hereby agree, that all employment claims, disputes and/or
controversies, whether against the Client Company/ProSource or another employee, that are not
resolved by management of the Client Company/ProSource, will be resolved in accordance with the
rules of the American Arbitration Association.
FINALLY, OUR “PLAIN” MISSION…
Every employee of ProSource and the Client Company should be dedicated and committed to conducting
business utilizing high ethical standards, treating everyone with dignity and respect. ProSource believes in
partnerships with our Client Companies and all employees in order to achieve excellence.
IF YOU HAVE ANY QUESTIONS, CONTACT YOUR SUPERVISIOR OR PROSOURCE.
Revised 2/08
6
RULES OF CONDUCT
POLICY STATEMENT
The following Rules of Conduct apply to all employees of Client Company contracted with ProSource
Management Solutions. Rules and regulations of acceptable conduct are necessary for the orderly
operation of an organization and the protection of employees, the company, and company clients. The
following rules, regulations and procedures for disciplinary actions are published to (i) promote
understanding of what is considered as unacceptable conduct, and (ii) to provide uniformity in disciplinary
action in the event a rule or regulation is violated. Herein, the use of the “Company” refers to the Client or
ProSource as it may apply.
For the purpose of uniform and progressive discipline, violation of these rules of conduct are categorized as
follows:
Major Offense: A “Major Offense” is a serious violation of Company standards of conduct. Such a
violation justifies immediate discharge without regard to the employee’s length of service or prior conduct. At
the sole option of the Company, the employee can be suspended without pay for up to three (3) work days
while the conduct is investigated by management. If the complaint of the Major Offense is correct and if
no circumstances are found to excuse the employee’s actions, his or her employment will be
immediately terminated.
Serious Offenses: A “Serious Offense” is a violation which does not justify immediate termination. The
employee shall receive a written warning and, at the sole option of the Company, can be suspended
without pay for up to three (3) work days.
Other Offenses: All offenses (other than “Major” and “Serious”): “Other Offenses”, must be addressed
though the offense may be less serious. Therefore, regarding all offenses, the employee is first verbally
warned with a notation to the employee’s file. If the problem continues, he or she is given a written
warning, a copy of which will be placed in the employee’s file.
Continued violation(s) will result in
suspension without pay (if, in the sole discretion of the Company, suspension is necessary), and finally
termination if the offense is not corrected.
While not all-inclusive, the following acts will be considered as requiring corrective action:
A.
Revised 2/08
Major Offenses That Can Lead To Immediate Termination
1. Violation of Company/Client policies or safety rules.
2. Theft or misappropriation of Company/Client, customer/patron, or employee property.
3. Falsification of personnel records, time cards, or other important Company/Client
information. This includes punching another employee’s timecard.
4. Willful defacement or damage of Company/Client property, the property of another
employee, or customer/patron property. Examples include loss of instruments/tools,
careless use of equipment, and improper disposing of materials.
5. Possession of firearms, explosives, or other lethal weapons on Company/Client property
or in Company/Client vehicles.
6. Reporting to work or working under the influence of intoxicating beverages and/or
narcotics, having the presence of these substances in your body, or possessing these
substances on Company/Client property or while on Company/Client business.
7. Refusing to take random, post-accident, or “for cause” drug test. This will be considered
a voluntary resignation of employment.
8. Selling, furnishing, or exchanging illegal substances on the job.
9. Refusing to carry our orders and instruction from your supervisor, and/or being
insubordinate.
10. Physically fighting or hitting any Company employee, customer/patron, or visitor.
11. Participation in work stoppage or excessively interfering with others in the performance of
their jobs.
12. Absence of three (3) consecutive work days without notifying the Company of the reason
for the absence. This will be considered a voluntary resignation due to job abandonment.
13. Committing two (2) “serious” offenses in a twelve (12) month period.
7
B.
Serious Offenses
First Offense:
Written warning/Possible Suspension
Second Offense: Termination (an employee may be suspended without pay for up to
three (3) days for fact finding investigation).
1. Sleeping or excessive loafing on the job
2. Neglect and/or disregard of assigned duties
3. Using threatening or abusive language to an employee, visitor, customer/patron or
supervisor
4. Harassment of any type, including religious, ethnic or sexual harassment
5. Disorderly, immoral, or indecent conduct
6. Removal of confidential information or records from Company/Client property without
management authorization
7. Unauthorized solicitation on Company/Client property without management authorization
8. Participating in unauthorized meetings or gatherings on Company/Client time and
property
9. Unauthorized use of Company/Client vehicles and equipment, including office equipment
10. Leaving the job without permission during working hours
11. Reporting to work under the influence of intoxicants or drugs
12. Failure to timely report an on-the-job injury, accident or damaged Company equipment
13. Without regard to “C” below, a “Serious Offense” may include, at the sole discretion of the
Company, an employee committing two (2) or more “Other” offenses within a twelve (12)
month period.
C.
Other Offenses
First Offense:
Verbal Warning
Second Offense: Written Warning
Third Offense:
Fourth Offense:
1.
2.
3.
4.
5.
6.
Revised 2/08
Written warning, suspension, and/or termination
Termination (including unpaid suspension up to three (3) days for
fact finding investigation)
Excessive absence and/or tardiness
Unsatisfactory or inefficient job performance
Failure to call in when late or absent
Failure to observe safety rules and failure to wear safety/personal protective
equipment, and participating in “horseplay”
Attending to personal business on Company/Client time
Leaving work station early for meal or breaks and/or the end of the shift
8
Texas Star NetworkSM
Employee Notice of
Network Requirements
Important Contact Information:
To locate a provider, call (800) 381-8067
To contact Texas Mutual Insurance Company, visit
www.texasmutual.com or call (800) 859-5995
Employee Notice of Network Requirements – 08/06
Page 1 of 9
Information, Instructions and your Rights and Obligations
Dear Employee:
Your employer has chosen Texas Star NetworkSM to manage the health care and treatment you
may receive if you are injured at work. Texas Star NetworkSM is a certified workers’
compensation health care network. The state of Texas has approved this network to provide care
for work related injuries. This program includes a network of health care providers who are
trained in treating work related injuries. They are also trained in getting people back to work
safely. The current Texas Star NetworkSM service areas are shown on the enclosed map.
If you are injured at work, tell your supervisor or employer immediately. The enclosed
information will help you to seek care for your injury. Also, your employer will help with any
questions about how to get treatment through Texas Star NetworkSM. You may also contact
Texas Mutual Insurance Company for any questions about your care and treatment for a work
related injury. Texas Mutual and your employer have formed a team to provide timely health
care for injured workers. The goal is to return you to work as soon as it is safe to do so.
Your Rights and Obligations...
Choosing a Treating Doctor
If you are hurt at work and you live in the network service area, you must choose a treating
doctor from the Texas Star NetworkSM provider list. This is required for you to receive coverage
of the costs for the care of your work related injury. A provider listing is available through our
website at www.texasmutual.com. It is updated at least every three months. It identifies
providers who are taking new patients.
You also have the option to choose your current health maintenance organization (HMO)
primary care physician as the treating doctor for your workers' compensation claim. In order for
your HMO doctor to be approved as your treating doctor, he/she must agree to the terms of the
network contract, and to agree to abide by applicable laws and regulations. If your HMO doctor
is not approved, then you must see a network treating doctor.
If you were injured before your insurer contracted with the network and you live in the service
area, you must choose a network treating doctor. You may also request a doctor you chose as your
HMO primary care doctor before you were hurt. You must do this upon receipt of this notice.
If your treating doctor leaves the network, we will tell you in writing. You will have the right to
choose another treating doctor from the list of network doctors. If your doctor leaves the network
Page 2 of 9
and you have a life threatening or acute condition for which a disruption of care would be harmful
to you, your doctor may request that you treat with him or her for an extra 90 days.
If you believe you live outside of the service area, you may request a service area review by
calling Texas Mutual Insurance Company. Within 7 days of receiving your request for review,
we will tell you our decision. If you do not agree with our final decision you have the right to
file a complaint with the Texas Department of Insurance. Your complaint must include your
name, address, telephone number, a copy of the insurer’s decision and any proof you sent to
Texas Mutual Insurance Company for review. A complaint form is available on the
department’s web site at www.tdi.state.tx.us. You may also ask for a form by writing to the
HMO Division, Mail Code 103-6A, Texas Department of Insurance, P. O. Box 149104, Austin,
Texas 78714-9104.
While waiting for Texas Mutual Insurance Company to make a decision or the Texas
Department of Insurance to review your complaint, you may choose to receive health care
outside of the network. You may be required to pay for health care services received out of the
network if it is finally decided that you do live in the network’s service area.
Changing Doctors
If you become dissatisfied with your first choice of a treating doctor, you can select an alternate
treating doctor from the list of network treating doctors in the service area where you live. Texas
Star NetworkSM will not deny a choice of an alternate treating doctor. Before you can change
treating doctors a second time, you must get permission from Texas Star NetworkSM.
Referrals
Health care services that you request will be made available on a timely basis as required by your
medical condition. This includes referrals. Referrals will be made no more than 21 days after
you make a request. You do not have to get a referral if you are in need of emergency care.
Payment for Health Care
Network doctors have agreed to look to Texas Mutual Insurance Company for payment for your
health care. They will not look to you for payment. If you obtain health care from a doctor who
is not in the network without prior approval from Texas Star NetworkSM, you may have to pay for
the cost of that care. You may only access non-network health care providers and still be eligible
for coverage of your medical costs if one of the following situations occurs.
• Emergency care is needed. You should go to the nearest hospital or emergency
care facility.
• You do not live within a Texas Star NetworkSM service area.
• Your treating doctor refers you to an out of network provider or facility. This
referral must be approved by Texas Star NetworkSM.
• You have chosen your HMO primary care doctor. Your doctor must agree to
abide by the network contract and applicable laws.
Page 3 of 9
Complaints
You have the right to file a complaint with Texas Star NetworkSM. You may do this if you are
dissatisfied with any aspect of network operations. This includes a complaint about your network
doctor. It may also be a general complaint about Texas Star NetworkSM.
A complainant can notify the Texas Star NetworkSM Grievance Coordinator of a complaint by
phone or in writing via mail or fax. Complaints should be forwarded to:
Attention: Grievance Coordinator
720 Cool Springs Boulevard, Suite 300
Franklin, TN 37067
Phone: (800) 873-0055 ext 4250
FAX: (615) 224-9129
E-mail: grievance_coordinator@concentra.com
A complaint must be filed with the network grievance coordinator no later than 90 days from the
date the issue occurred.
Texas law does not permit Texas Star NetworkSM to retaliate against you if you file a complaint
against the network. Texas Star NetworkSM also can not retaliate if you appeal the decision of the
network. The law does not permit Texas Star NetworkSM to retaliate against your treating doctor
if he or she files a complaint against the network or appeals the decision of the network on your
behalf. You have the right to file a complaint with the Texas Department of Insurance. The
Texas Department of Insurance complaint form is available on the department’s web site at
www.tdi.state.tx.us or you may request a form by writing to:
HMO Division, Mail Code 103-6A,
Texas Department of Insurance,
P. O. Box 149104, Austin, Texas 78714-9104.
Page 4 of 9
What to do if you are injured while on the job...
If you are injured while on the job tell your employer as soon as possible. A list of network
treating doctors in your service area may be available from your employer. A complete list of
network treating doctors is also available online at www.texasmutual.com. Or, you may contact
us directly at the following address and/or toll-free telephone number:
720 Cool Springs Boulevard
Suite 300
Franklin, TN 37067
(800) 873-0055
We will help you get an appointment with a network doctor.
________________________________________________________________________
In case of an emergency…
If you are hurt at work and it is a life threatening emergency, you should go to the nearest
emergency room. If you are injured at work after normal business hours or while working outside
your service area, you should go to the nearest care facility.
After you receive emergency care, you may need ongoing care. You will need to select a
treating doctor from the network’s provider list.
This list is available online at
www.texasmutual.com. If you do not have internet access call (800) 381-8067 or contact your
employer for a list. The doctor you choose will oversee the care you receive for your work
related injury. Except for emergency care you must obtain all health care and specialist referrals
through your treating doctor.
Emergency care does not need to be approved in advance. “Medical emergency” is defined
in Texas laws. It is a medical condition that comes up suddenly. There are acute symptoms that
are severe enough that a reasonable person would believe that you need immediate care or you
would be harmed. That harm would include your health or bodily functions being in danger or a
loss of function of any body organ or part.
Non-emergency care…
Report your injury to your employer as soon as you can. Select a treating doctor from the
network’s provider list. This list is available online at www.texasmutual.com. If you do not
have internet access, call (800) 381-8067 or contact your employer for a list.
Treatment prescribed by your doctor may need to be approved in advance. You or your doctor
are required to request approval from Texas Mutual Insurance Company for a specific treatment
or services before the treatment or service is provided. You may continue to need treatment after
the approved treatment is provided. For example, you may need to stay more days in the
hospital than what was first approved. If so, the added treatment must be approved in advance.
Page 5 of 9
The following treatment requests must be approved in advance:
Acupuncture
All surgeries
Aquatic therapy
Artificial disc surgery
Biofeedback and pain management, initial evaluation
and “full” chronic pain management programs (initial
referral does not require approval)
Bone density scans
Botox injections
Chemonucleolysis
Chiropractic treatments greater than 8 visits
Dental work over $1000
Diagnostic procedures other than x-rays, i.e.,
magnetic resonance imaging (MRI), computerized
axial tomography (CT scan)
Discograms
Durable medical equipment greater than $500
Electromyography (EMG) and nerve conduction
velocity (NCV) testing
Epidural steroid injections
External and implantable bone growth stimulators
Facet injections
Gym memberships
Home health care/aides physical therapy/aides
Home health nursing
Interferential units
Intradiscal Electrothermal Annuloplasty (IDET)
Inpatient hospitalization
Investigational or experimental
procedures/medications/devices
Joint steroid injections
Manipulations under anesthesia
Massage therapy
Morphine pain pump
Myelograms
Neuromuscluar stimulator devices
Nursing home, skilled nursing facility, convalescent
or residential care admissions
Occupational therapy treatments greater than 8 visits
Orthotic devices
Physical therapy treatments greater than 8 visits
Prolotherapy
Psychological testing
Psychotherapy, with social worker, psychologist or
psychiatrist
Radiofrequency Thermocoagulation (RFTC) of facets
joints
Rehab services
Repeat diagnostics and MRI’s (MRI/Scan of the
spine within the first 4 weeks or repeat of all MRI for
all body parts)
Requests for long-term medications, especially
narcotics
RFTC or cryotherapy/cryoablation of any nerve or
joint
Sacral Iliac joint injection
Skilled nursing visits
Spine surgery for more than one level
TENS units
Trigger point injections
Vax-D
Weight loss programs
Work hardening/work conditioning greater than two
weeks
The number to call to request one of these treatments is (888) 532-5246. If a treatment or service
request is denied, we will tell you in writing. This written notice will have information about
your right to request a reconsideration or appeal of the denied treatment. It will also tell you
about your right to request review by an Independent Review Organization through the Texas
Department of Insurance.
Page 6 of 9
Texas Star Network
SM
Service Area Map (As of August 2006)
Network service areas are subject to change
– A list of counties is contained on the next page –
Page 7 of 9
Texas Star Network
SM
Service Area County List (As of August 2006)
Network service areas are subject to change
ANDERSON
ARANSAS
ARMSTRONG
ATASCOSA
AUSTIN
BANDERA
BASTROP
BEE
BELL
BEXAR
BLANCO
BOSQUE
BRAZORIA
BRAZOS
BROOKS
BROWN
BURLESON
BURNET
CALDWELL
CALHOUN
CAMERON
CAMP
CARSON
CHAMBERS
CHEROKEE
COLEMAN
COLLIN
COLORADO
COMAL
COMANCHE
CONCHO
COOKE
CORYELL
CROSBY
DALLAS
DEAF SMITH
DELTA
DENTON
DEWITT
DUVAL
EASTLAND
EL PASO
ELLIS
ERATH
FALLS
FANNIN
FAYETTE
FORT BEND
FRANKLIN
FREESTONE
FRIO
GALVESTON
GILLESPIE
GOLIAD
GONZALES
GREGG
GRIMES
GUADALUPE
HALE
HAMILTON
HARDIN
HARRIS
HARRISON
HAYS
HENDERSON
HIDALGO
HILL
HOCKLEY
HOOD
HOPKINS
HOUSTON
HUNT
HUTCHINSON
IRION
JACK
JACKSON
JEFFERSON
JIM HOGG
JIM WELLS
JOHNSON
KARNES
KAUFMAN
KENDALL
KENEDY
KERR
KLEBERG
LAMB
LAMPASAS
LAVACA
LEE
LEON
LIBERTY
LIMESTONE
LIVE OAK
LLANO
LUBBOCK
LYNN
MADISON
MATAGORDA
MCCULLOCH
MCLENNAN
MCMULLEN
MEDINA
MENARD
MILAM
MILLS
MONTAGUE
MONTGOMERY
MOORE
MORRIS
NAVARRO
NUECES
OLDHAM
PALO PINTO
PANOLA
PARKER
POTTER
RAINS
RANDALL
REFUGIO
ROBERTSON
ROCKWALL
RUSK
SAN JACINTO
SAN PATRICIO
SAN SABA
SMITH
SOMERVELL
STARR
STEPHENS
TARRANT
TERRY
TITUS
TOM GREEN
TRAVIS
TRINITY
UPSHUR
VAN ZANDT
VICTORIA
WALKER
WALLER
WASHINGTON
WHARTON
WILLACY
WILLIAMSON
WILSON
WISE
WOOD
YOAKUM
Page 8 of 9

1502 Augusta Drive • Suite 100 •Houston, TX 77057 • 1-888-667-3690

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