Employment Applicati..

19 Pages·2010·0.64 MB·English

Dear Prospective Employee:

In addition to the application and forms attached, you also need to provide us with:

Security Guard
1. A photocopy of your New York State Guard Card.
2. A photocopy of your Driver’s License.
3. A photocopy of your Social Security Card, or Birth Certificate.
4. Or you can provide a photocopy of your US Passport instead of #2 and #3 above.

Armed Guard
1. A photocopy of your New York State Guard Card.
2. A photocopy of your New York State Pistol Permit.
3. A photocopy of your Driver’s License.
4. A photocopy of your Social Security Card, or Birth Certificate.
5. Or you can provide a photocopy of your US Passport instead of #3 and #4 above.

Policeman
1. A photocopy of your current Police ID card.
2. A photocopy of your Driver’s License.
3. A photocopy of your Social Security Card, or Birth Certificate.
4. Or you can provide a photocopy of your US Passport instead of #2 and #3 above.

Please note that if you are a retired policeman, please follow the Security Guard or Armed Guard
list.

BPI does offer direct deposit, if you are interested please contact me for a form.

If you have any questions, please do not hesitate to contact me at 716-432-8220 or
[email protected]

Thanks for your interest in working for Buffalo Protection & Investigation, Inc.

Regards,
Mona T. Rinaldo
DMireTctRor of Operations

605 Division Street • N. Tonawanda, NY 14120 • Tel: [phone] • Fax: [phone]
W W W . BUF F AL OPI. C OM
Company Name _______________________________________ Date

Please Print Clearly APPLICATION FOR EMPLOYMENT

Please Answer All Questions. Résumés Are Not A Substitute For A Completed Application.

We are an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed
servicemember status, race, religion, sex, national origin, age, physical or mental disability, genetic information or any other
category protected by applicable federal, state, or local laws.

THIS COMPANY IS AN AT-WILL EMPLOYER AS ALLOWED BY APPLICABLE STATE LAW. THIS MEANS THAT
REGARDLESS OF ANY PROVISION IN THIS APPLICATION, IF HIRED, THE COMPANY OR I MAY TERMINATE THE
EMPLOYMENT RELATIONSHIP AT ANY TIME, FOR ANY REASON, WITH OR WITHOUT CAUSE OR NOTICE.

Position Applied For ____________________________________ Name

Telephone Number ( ) _______-_________ Alternate or Cellular Telephone Number ( ) _______-____________

Present Address _____________________________________________________________________________________________
Street, Apartment, or Unit Number
____________________________________________ __________ ___________ How long have you lived there _____/______
City State Zip Years/Months
Previous Address ____________________________________________________________________________________________
Street, Apartment, or Unit Number
____________________________________________ __________ ___________ How long have you lived there _____/______
City State Zip Years/Months

Desired Salary/Hourly Rate ____________________

If under the age of 18, can you produce the necessary work certificate at the time of employment? Yes (cid:137) No (cid:137)

Type of employment desired? Full-time (cid:137) Part-time (cid:137) (Specify Hours)

Are you willing to work overtime? Yes (cid:137) No (cid:137) Date on which you can start work if hired

Have you previously applied for employment with this Company? Yes (cid:137) No (cid:137)

If Yes, when and where did you apply?

Have you ever been employed by this Company? Yes (cid:137) No (cid:137) If Yes, provide dates of employment, location, and reason for
separation from employment.

INSTRUCTIONS FOR ANSWERING THE NEXT TWO QUESTIONS
1. All applicants: Do not include convictions that were sealed, eradicated, erased, annulled by a court, or expunged, or convictions that
resulted in referral to a diversion program.
2. Arizona, Colorado, District of Columbia, Illinois, Kansas, Minnesota, Missouri, Montana, Nevada, Rhode Island, South Carolina,
and Utah applicants: Do not respond to the second question regarding arrests.
3. California applicants: Do not include misdemeanor marijuana-related convictions that are more than two (2) years old or
misdemeanor convictions for which probation was successfully completed or otherwise discharged and the case was judicially
dismissed.
4. Connecticut applicants: You are not required to disclose the existence of any arrest, criminal charge, or conviction, the records of
which have been erased. Criminal records subject to erasure are records pertaining to a finding of delinquency or the fact that a child
was a member of a family with service needs, an adjudication as a youthful offender, a criminal charge that has been dismissed or
nolled (not prosecuted), a criminal charge for which the person was found not guilty, or a conviction for which the offender received
an absolute pardon. Any person whose criminal records have been erased is deemed to have never been arrested within the meaning
of the law as it applies to the particular proceedings that have been erased, and may so swear under oath.
5. District of Columbia and Washington applicants: Limit any response to the past ten (10) years.
6. Hawaii and Massachusetts applicants: Do not answer the following two questions.
7. Indiana applicants: Regarding arrests limit your response to pending charges for felonies and class A misdemeanors that are less than
one (1) year old.

Supervisor Procedures Manual RECRUITMENT, INTERVIEWING AND SELECTION 2:51
8. Michigan applicants: Regarding arrests, limit your response to felony arrests awaiting conviction or dismissal.
9. New York applicants: All pending arrests or criminal accusations must be disclosed. You are not required to disclose arrests or
criminal accusations that resulted in criminal actions or proceedings which were terminated in your favor. Do not disclose criminal
actions or proceedings that were sealed or classified as youthful offender adjudications. An ex-offender who is denied employment
may, upon written request, receive a statement of the reason(s) for denial within thirty (30) days of the applicant’s request for such
information.
10. North Dakota and Oregon applicants: Regarding arrests, limit your response to pending charges that are less than one (1) year old.
11. Utah applicants: Limit any response to felony convictions only. Do not respond to the second question regarding arrests.

Have you ever plead guilty or no contest to, or been convicted of any criminal offense other than the applicable exceptions listed above?
Yes (cid:137) No (cid:137)

Have you ever been arrested for any matters for which you currently are out on bail or on your own recognizance pending trial?
Yes (cid:137) No (cid:137)

CRIMINAL OFFENSES ONLY: If you answered Yes, to either of the above two questions, please provide the date(s) and explain in
accordance with the above instructions so that individual circumstances can be considered.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Criminal convictions or arrests will not automatically disqualify an applicant from a particular job. The Company will consider the
nature of the crime, its seriousness, the substantial relation to the position’s functions and qualifications, the number of occurrences,
the applicant’s age at the time of the crime, the time elapsed since the crime, the applicant’s entire work and educational history,
employment references and recommendations, and the business necessity of any exclusion when required by law.

Have you ever initiated an act of violence in the workplace? Yes (cid:137) No (cid:137)

If Yes, please provide the date(s) and explain so that individual circumstances can be considered. (A “Yes” answer will not necessarily
disqualify you from employment.)

List all special technical skills that you feel qualify you for the job for which you are applying (For example., computer
programming/language, software, equipment operation, special tools or machines, etc.)

__________________________________________________________________________________________________________

Education School Name and Location Course of Graduate? # of Years Degree/Major
(Address, City, State) Study Completed

High School

College

Bus./Tech./Trade

or Post College

Honors Received _______________________________________________________________________________________________

If applicable, list below any other names by which you have been known which may be necessary to allow us to confirm your work and
educational record. For example, change of name, use of an assumed name, nickname, etc.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Supervisor Procedures Manual RECRUITMENT, INTERVIEWING AND SELECTION 2:52
WORK EXPERIENCE
Please list the names of your present and/or previous employers in chronological order with present or last employer listed first. Account
for all periods of time including any period of unemployment. If self-employed, supply firm name and business references. You may
include any verifiable work performed on a volunteer basis, internships, or military service. Your failure to completely respond to each
inquiry may disqualify you for consideration from employment.

Employer
_________________________________________ ____________________________________
Name Address Type of Business

Telephone ( ) - Dates Employed From / /_____ To / /

Job Title Duties

Supervisor’s Name May we contact? (cid:137) Yes (cid:137) No If No, why not?

Wages Start Final Reason for Leaving

What will this employer say was the reason your employment terminated? ____________________________________________________________

How much notice did you give when resigning? If none, explain.

Employer
_________________________________________ ____________________________________
Name Address Type of Business

Telephone ( ) - Dates Employed From / /_____ To / /

Job Title Duties

Supervisor’s Name May we contact? (cid:137) Yes (cid:137) No If No, why not?

Wages Start Final Reason for Leaving

What will this employer say was the reason your employment terminated? ____________________________________________________________

How much notice did you give when resigning? If none, explain.

Employer
_________________________________________ ____________________________________
Name Address Type of Business

Telephone ( ) - Dates Employed From / /_____ To / /

Job Title Duties

Supervisor’s Name May we contact? (cid:137) Yes (cid:137) No If No, why not?

Wages Start Final Reason for Leaving

What will this employer say was the reason your employment terminated? ____________________________________________________________

How much notice did you give when resigning? If none, explain.

Please explain fully all gaps in your employment history in excess of one month.

Have you ever been terminated or asked to resign from any job? (cid:137) Yes (cid:137) No. If Yes, how many times? ________
Has your employment ever been terminated by mutual agreement? (cid:137) Yes (cid:137) No If Yes, how many times? ________
Have you ever been given the choice to resign rather than be terminated? (cid:137) Yes (cid:137) No If Yes, how many times? ________
If you answered Yes to any of the above three questions, please explain the circumstances of each occasion.

Supervisor Procedures Manual RECRUITMENT, INTERVIEWING AND SELECTION 2:53
REFERENCES
Please list the names of additional work-related references we may contact. Individuals with no prior work experience may list school or
volunteer-related references.

NAME POSITION COMPANY WORK RELATIONSHIP TELEPHONE
(i.e., supervisor, co-worker)

Please list the names of personal references (not previous employers or relatives) who know you well that we may contact.
NAME OCCUPATION ADDRESS TELEPHONE NUMBER OF
YEARS KNOWN

APPLICANT CERTIFICATION

I understand and agree that if driving is a requirement of the job for which I am applying, my employment and/or continued employment
is contingent on possessing a valid driver’s license for the state in which I reside and automobile liability insurance in an amount equal to
the minimum required by the state where I reside.

I understand that the Company may now have, or may establish, a drug-free workplace or drug and/or alcohol testing program consistent
with applicable federal, state, and local law. If the Company has such a program and I am offered a conditional offer of employment, I
understand that if a pre-employment (post-offer) drug and/or alcohol test is positive, the employment offer may be withdrawn. I agree to
work under the conditions requiring a drug-free workplace, consistent with applicable federal, state, and local law. I also understand that
all employees of the location, pursuant to the Company’s policy and federal, state, and local law, may be subject to urinalysis and/or
blood screening or other medically recognized tests designed to detect the presence of alcohol or illegal or controlled drugs. If employed,
I understand that the taking of alcohol and/or drug tests is a condition of continual employment and I agree to undergo alcohol and drug
testing consistent with the Company’s policies and applicable federal, state, and local law.

If employed by the Company, I understand and agree that the Company, to the extent permitted by federal, state, and local law, may
exercise its right, without prior warning or notice, to conduct investigations of property (including, but not limited to, files, lockers,
desks, vehicles, and computers) and, in certain circumstances, my personal property.

I understand and agree that as a condition of employment and to the extent permitted by federal, state, and local law, I may be required to
sign a confidentiality, restrictive covenant, and/or conflict of interest statement, as well as an agreement to arbitrate.

I certify that all the information on this application, my résumé, or any supporting documents I may present during any interview is and
will be complete and accurate to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of any
information may result in disqualification from consideration for employment or, if employed, disciplinary action, up to and including
immediate dismissal.

THIS COMPANY IS AN AT-WILL EMPLOYER AS ALLOWED BY APPLICABLE STATE LAW. THIS MEANS THAT
REGARDLESS OF ANY PROVISION IN THIS APPLICATION, IF HIRED, THE COMPANY OR I MAY TERMINATE THE
EMPLOYMENT RELATIONSHIP AT ANY TIME, FOR ANY REASON, WITH OR WITHOUT CAUSE OR NOTICE.
NOTHING IN THIS APPLICATION OR IN ANY DOCUMENT OR STATEMENT, WRITTEN OR ORAL, SHALL LIMIT
THE RIGHT TO TERMINATE EMPLOYMENT AT-WILL. NO OFFICER, EMPLOYEE OR REPRESENTATIVE OF THE
COMPANY IS AUTHORIZED TO ENTER INTO AN AGREEMENT—EXPRESS OR IMPLIED—WITH ME OR ANY
APPLICANT FOR EMPLOYMENT FOR A SPECIFIED PERIOD OF TIME UNLESS SUCH AN AGREEMENT IS IN A
WRITTEN CONTRACT SIGNED BY THE PRESIDENT OF THE COMPANY.

IF HIRED, I AGREE TO CONFORM TO THE RULES AND REGULATIONS OF THE COMPANY, AND I UNDERSTAND THAT
THE COMPANY HAS COMPLETE DISCRETION TO MODIFY SUCH RULES AND REGULATIONS AT ANY TIME, EXCEPT
THAT IT WILL NOT MODIFY ITS POLICY OF EMPLOYMENT AT-WILL.

Supervisor Procedures Manual RECRUITMENT, INTERVIEWING AND SELECTION 2:54
I authorize the Company or its agents to confirm all statements contained in this application and/or résumé as it relates to the position I
am seeking and to the extent permitted by federal, state, or local law. I agree to complete any requisite authorization forms for the
background investigation.

I authorize and consent to, without reservation, any party or agency contacted by this employer to furnish the above-mentioned
information. I hereby release, discharge, and hold harmless, to the extent permitted by federal, state, and local law, any party delivering
information to the Company or its duly authorized representative pursuant to this authorization from any liability, claims, charges, or
causes of action which I may have as a result of the delivery or disclosure of the above requested information. I hereby release from
liability the Company and its representative for seeking such information and all other persons, corporations, or organizations furnishing
such information.

If hired by this Company, I understand that I will be required to provide genuine documentation establishing my identity and eligibility to
be legally employed in the United States by this Company. I also understand this Company employs only individuals who are legally
eligible to work in the United States.

THIS APPLICATION WILL BE CONSIDERED ACTIVE FOR A MAXIMUM OF SIXTY (60) DAYS. IF YOU WISH TO BE
CONSIDERED FOR EMPLOYMENT AFTER THAT TIME, YOU MUST REAPPLY.

I CERTIFY THAT ALL OF THE INFORMATION THAT I HAVE PROVIDED ON THIS APPLICATION IS TRUE, ACCURATE,
AND COMPLETE.

Applicant Signature Date / /

If the applicant is a minor, the foregoing release and consent must be signed by the applicant’s parent or legal guardian. Signature by the applicant’s
parent or legal guardian constitutes acknowledgement by the applicant and the parent or legal guardian that the Company, to the extent permitted by
federal, state, and local law, can test the applicant for illegal or controlled substances, conduct inspections of property without notice, and communicate
test results to Company personnel who need to know, the applicant, and the applicant’s legal guardian.

Parent/Legal Guardian Witness

Date Date

UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT,
PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A LIE
DETECTOR, POLYGRAPH, OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR
AND SUBJECT TO A FINE NOT EXCEEDING $100. I have read and understand the above statement.

Applicant Signature Date / /

UNDER MASSACHUSETTS LAW, IT IS UNLAWFUL FOR AN EMPLOYER TO REQUIRE OR TO ADMINISTER A LIE DETECTOR,
POLYGRAPH OR SIMILAR TEST AS A CONDITION OF EMPLOYMENT OR CONTINUED EMPLOYMENT.

FEDERAL AND/OR STATE LAW MAY PROHIBIT THE USE OF LIE DETECTOR, POLYGRAPH OR SIMILAR TEST AS WELL.

THIS APPLICATION MAY NOT BE APPLICABLE FOR ALL INDUSTRIES.

©2010 Paychex, Inc 151508/154425 11/10

Supervisor Procedures Manual RECRUITMENT, INTERVIEWING AND SELECTION 2:55
New Employee Information

Employer Complete

(cid:134) New Hire (cid:134) Rehire Previous Name (if applicable)

EMPLOYMENT DATA

Job Title Date of Hire / /

Rate of Pay Grade

(cid:134) Hourly (cid:134) Salaried
(cid:134) Full-time (cid:134) Part-time
(cid:134) Seasonal - Scheduled Days and Hours

Supervisor/Manager Signature Date / /

Employee Complete

PERSONAL DATA

Last Name First Name Initial

Address

City State Zip Code

Telephone Number ( ) - Date of Birth / /

EMERGENCY CONTACT INFORMATION

Name Relationship

Emergency Telephone Number ( ) -

Employee Signature Date / /

11/07
Supervisor Procedures Manual MANAGING EMPLOYEES IN THE WORKPLACE 3:45
Form W-4 (2010) Complete all worksheets that apply. However, you payments using Form 1040-ES, Estimated Tax
may claim fewer (or zero) allowances. For regular for Individuals. Otherwise, you may owe
wages, withholding must be based on allowances additional tax. If you have pension or annuity
Purpose. Complete Form W-4 so that your you claimed and may not be a flat amount or income, see Pub. 919 to find out if you should
employer can withhold the correct federal income percentage of wages. adjust your withholding on Form W-4 or W-4P.
tax from your pay. Consider completing a new Head of household. Generally, you may claim Two earners or multiple jobs. If you have a
Form W-4 each year and when your personal or head of household filing status on your tax working spouse or more than one job, figure
financial situation changes. return only if you are unmarried and pay more the total number of allowances you are entitled
Exemption from withholding. If you are than 50% of the costs of keeping up a home to claim on all jobs using worksheets from only
exempt, complete only lines 1, 2, 3, 4, and 7 for yourself and your dependent(s) or other one Form W-4. Your withholding usually will
and sign the form to validate it. Your exemption qualifying individuals. See Pub. 501, be most accurate when all allowances are
for 2010 expires February 16, 2011. See Exemptions, Standard Deduction, and Filing claimed on the Form W-4 for the highest
Pub. 505, Tax Withholding and Estimated Tax. Information, for information. paying job and zero allowances are claimed on
the others. See Pub. 919 for details.
Note. You cannot claim exemption from Tax credits. You can take projected tax
withholding if (a) your income exceeds $950 credits into account in figuring your allowable Nonresident alien. If you are a nonresident
and includes more than $300 of unearned number of withholding allowances. Credits for alien, see Notice 1392, Supplemental Form
income (for example, interest and dividends) child or dependent care expenses and the W-4 Instructions for Nonresident Aliens, before
and (b) another person can claim you as a child tax credit may be claimed using the completing this form.
dependent on his or her tax return. Personal Allowances Worksheet below. See
Check your withholding. After your Form W-4
Basic instructions. If you are not exempt, Pub. 919, How Do I Adjust My Tax takes effect, use Pub. 919 to see how the
complete the Personal Allowances Worksheet Withholding, for information on converting amount you are having withheld compares to
your other credits into withholding allowances.
below. The worksheets on page 2 further adjust your projected total tax for 2010. See Pub.
your withholding allowances based on itemized Nonwage income. If you have a large amount 919, especially if your earnings exceed
deductions, certain credits, adjustments to of nonwage income, such as interest or $130,000 (Single) or $180,000 (Married).
income, or two-earners/multiple jobs situations. dividends, consider making estimated tax
Personal Allowances Worksheet (Keep for your records.)
A Enter “1”for yourself if no one else can claim you as a dependent A
(cid:2) ● You are single and have only one job; or (cid:3)
B Enter “1”if: ● You are married, have only one job, and your spouse does not work; or B
● Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.
C Enter “1” for your spouse. But, you may choose to enter “-0-”ifyou are married and have either a working spouse or
more than one job. (Entering “-0-”mayhelp you avoid having too little tax withheld.) C
D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return D
E Enter “1”ifyou will file as head of household on your tax return (see conditions under Head of household above) E
F Enter “1” if you have at least $1,800 of child or dependent care expenses for which you plan to claim a credit F
(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
child plus “1” additional if you have six or more eligible children. G
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.)(cid:3) H
For accuracy, (cid:2) ● If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions
complete all and Adjustments Worksheet on page 2.
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
that apply. $18,000 ($32,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld.
● 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.
W-4
Employee’s Withholding Allowance Certificate OMB No. 1545-0074
10
Form
Department of the Treasury (cid:3) Whether you are entitled to claim a certain number of allowances or exemption from withholding is
Internal Revenue Service subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
1 Type or print your first name and middle initial. Last name 2 Your social security number
Home address (number and street or rural route) 3
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.
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. (cid:3)
5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 5
6 Additional amount, if any, you want withheld from each paycheck 6 $
7 I claim exemption from withholding for 2010, 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 (cid:3) 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.) (cid:3) Date (cid:3)
8 Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.) 9Office code (optional) 10 Employer identification number (EIN)
For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 10220Q Form W-4 (2010)
Form W-4 (2010) Page 2
Deductions and Adjustments Worksheet
Note.Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.
1 Enter an estimate of your 2010 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 1 $
(cid:2) $11,400 if married filing jointly or qualifying widow(er) (cid:3)
2 Enter: $8,400 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 2010 adjustments to income and any additional standard deduction. (Pub. 919) 4 $
5 Add lines 3 and 4 and enter the total. (Include any amount for credits from Worksheet 6 in Pub. 919.) 5 $
6 Enter an estimate of your 2010 nonwage income (such as dividends or interest) 6 $
7 Subtract line 6 from line 5. If zero or less, enter “-0-” 7 $
8 Divide the amount on line 7 by $3,650 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) 1
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 $65,000 or less, do not enter more
than “3.” 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 figure the additional
withholding amount necessary to avoid a year-end tax bill.
4 Enter the number from line 2 of this worksheet 4
5 Enter the number from line 1 of this worksheet 5
6 Subtract line 5 from line 4 6
7 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here 7 $
8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed 8 $
9 Divide line 8 by the number of pay periods remaining in 2010. For example, divide by 26 if you are paid
every two weeks and you complete this form in December 2009. Enter the result here and on Form W-4,
line 6, page 1. This is the additional amount to be withheld from each paycheck 9 $
Table 1 Table 2
Married Filing Jointly All Others Married Filing Jointly All Others
If wages from LOWEST Enter on If wages from LOWEST Enter on If wages from HIGHEST Enter on If wages from HIGHEST Enter on
paying job are— line 2 above paying job are— line 2 above paying job are— line 7 above paying job are— line 7 above
$0 - $7,000 - 0 $0 - $6,000 - 0 $0 - $65,000 $550 $0 - $35,000 $550
7,001 - 10,000 - 1 6,001 - 12,000 - 1 65,001 - 120,000 910 35,001 - 90,000 910
10,001 - 16,000 - 2 12,001 - 19,000 - 2 120,001 - 185,000 1,020 90,001 - 165,000 1,020
16,001 - 22,000 - 3 19,001 - 26,000 - 3 185,001 - 330,000 1,200 165,001 - 370,000 1,200
22,001 - 27,000 - 4 26,001 - 35,000 - 4 330,001 and over 1,280 370,001 and over 1,280
27,001 - 35,000 - 5 35,001 - 50,000 - 5
35,001 - 44,000 - 6 50,001 - 65,000 - 6
44,001 - 50,000 - 7 65,001 - 80,000 - 7
50,001 - 55,000 - 8 80,001 - 90,000 - 8
55,001 - 65,000 - 9 90,001 -120,000 - 9
65,001 - 72,000 - 10 120,001 and over 10
72,001 - 85,000 - 11
85,001 -105,000 - 12
105,001 -115,000 - 13
115,001 -130,000 - 14
130,001 - and over 15
Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this You are not required to provide the information requested on a form that is
form to carry out the Internal Revenue laws of the United States. Internal Revenue Code subject to the Paperwork Reduction Act unless the form displays a valid OMB
sections 3402(f)(2) and 6109 and their regulations require you to provide this control number. Books or records relating to a form or its instructions must be
information; your employer uses it to determine your federal income tax withholding. retained as long as their contents may become material in the administration of
Failure to provide a properly completed form will result in your being treated as a single any Internal Revenue law. Generally, tax returns and return information are
person who claims no withholding allowances; providing fraudulent information may confidential, as required by Code section 6103.
subject you to penalties. Routine uses of this information include giving it to the The average time and expenses required to complete and file this form will vary
Department of Justice for civil and criminal litigation, to cities, states, the District of depending on individual circumstances. For estimated averages, see the
Columbia, and U.S. commonwealths and possessions for use in administering their tax instructions for your income tax return.
laws, and using it in the National Directory of New Hires. We may also disclose this If you have suggestions for making this form simpler, we would be happy to hear
information to other countries under a tax treaty, to federal and state agencies to from you. See the instructions for your income tax return.
enforce federal nontax criminal laws, or to federal law enforcement and intelligence
agencies to combat terrorism.
OMB No. 1615-0047; Expires 08/31/12
Form I-9, Employment
Department of Homeland Security
Eligibility Verification
U.S. Citizenship and Immigration Services
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 Middle Initial Maiden Name
Address (Street Name and Number) Apt. # Date of Birth (month/day/year)
City State 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 A citizen of the United States
use of false documents in connection with the A noncitizen national of the United States (see instructions)
completion of this form. A lawful permanent resident (Alien #)

An alien authorized to work (Alien # or Admission #)
until (expiration date, if applicable - month/day/year)
Employee's Signature Date (month/day/year)
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) Date (month/day/year)
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 #:
Expiration Date (if any):
Document #:
Expiration Date (if any):
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
(month/day/year) and that to the best of my knowledge the employee is authorized to work in the United States. (State
employment agencies may omit the date the employee began employment.)
Signature of Employer or Authorized Representative Print Name Title
Business or Organization Name and Address (Street Name and Number, City, State, Zip Code) Date (month/day/year)
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 #: Expiration Date (if any):
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.
Signature of Employer or Authorized Representative Date (month/day/year)
Form I-9 (Rev. 08/07/09) Y Page 4