AFFIRMATIVE ACTION VOLUNTARY SELF IDENTIFICATION FORM · AFFIRMATIVE ACTION VOLUNTARY SELF IDENTIFICATION FORM It is the policy of Liesfeld to affoid equal opportunity to all employees

AFFIRMATIVE ACTION VOLUNTARY SELF IDENTIFICATION FORM

It is the policy of Liesfeld to affoid equal opportunity to all employees and applicants for employment without regard to age. race, religion, color, sex, national origin, marital status, expunged juvenile .records, or pregnancy, and to afford equal opportunities to disabled veterans, veterans of the Vietnam era, and individuals with a disability, and all other characteristics protected by Federal, State or Local law.

Government agencies require Liesfeld to collect and report this information as part of our -Affirmative-Action Program- -Submission is voluntary. Providing or declining to provide the personal identification information requested will not jeopardize or adversely affect any employment consideration However, completion of this form is required in order to be consider ed for employment with Liesfeld.

Name Date / /

Position applied for

Race or Ethnic Identity Hispanic or Latino White (not Hispanic or Latino) Black or African American (not Hispanic or Latino) :

Native Hawaiian or Pacific Islander (not Hispanic or Latino) Asian (not Hispanic or Latino) Amer ican Indian or Alaskan Native (not Hispanic or Latino) Iwo or More Races (not Hispanic or Latino)

Gender Male Female

** Veteran Status **Other • ; Vietnam Er a Veter an Individual with Disabilities Special Disabled Veteran Other Eligible Veter an

I do not wish to Self-Identify: Signature

For Human Resources Use Only: 5 Requisition # Job Group

... i •;

/ / C O N T R A C T O R , INC..

Application for Employment

Conditions of employment are stated at the end of this form Please read carefully before you sign this application (Application must be completed in fuii even if attaching a resume )

POSITION APPLYING FOR: DATE OF APPLICATION:

PERSONAL PLEASE PRINT USING BALLPOINT PEN

FULL NAME

FIRST MIDDLE LAST SOCIAL SECURITY NUMBER

PRESENT ADDRESS

STATE ZIP H O W LONG

PREVIOUS ADDRESS

STATE ZIP H O W LONG

PRIMARY PHONE#: SECONDARY PHONE#:

ARE ANY OF YOUR RELATIVES PRESENTLY EMPLOYED WITH THE COMPANY OR ITS DIVISIONS? IF YES, NAME OF RELATIVE:

Y E S [ ] N O

HAVE YOU EVER WORKED FOR THE COMPANY OR ITS DIVISIONS BEFORE? [ ] YES [ ] NO IF YES, WHERE? APPROXIMATE DATE (MO/YR.):

HAVE YOU EVER APPLIED FOR THE COMPANY OR ITS DIVISIONS BEFORE? [ ] YES [ ] NO IF YES, WHERE? APPROXIMATE DATE (MO/YR.):

GENERAL INFORMATION IF YOU ARE UNDER AGE 18, PLEASE STATE YOUR AGE:

IF UNDER AGE 18, CAN YOU SUPPLY WORKING PAPERS? f ] YES r 1NO

ONLY U S CITIZENS OR ALIENS WHO HAVE A LEGAL RIGHT TO WORK IN THE U.S. ARE ELIGIBLE FOR EMPLOYMENT. CAN YOU, UPON EMPLOYMENT PROVIDE GENUINE DOCUMENTATION ESTABLISHING YOUR IDENTITY AND ELIGIBILITY TO BE LEGALLY EMPLOYED IN THE UNITED STATES? [ ] YES [ } NO

HAVE YOU EVER BEEN CONVICTED OF A CRIME OR VIOLATION OTHER THAN A MINOR TRAFFIC INFRACTION (A CONVICTION RECORD WILL NOT NECESSARILY BE A BAR TO EMPLOYMENT FACTORS SUCH AS JOB RELATIONS, AGE AND TIME OF THE OFFENSE, SERIOUSNESS AND NATURE OF VIOLATION AND REHABILITATION WILL BE TAKEN INTO ACCOUNT) [ ] YES { ] NO IF YES, PLEASE EXPLAIN:

HAVE YOU EVER BEEN DISCHARGED FROM ANY EMPLOYMENT OR ASKED TO RESIGN OR DISHONORABLY DISCHARGED FROM THE MILITARY? [ ] YES [ ] NO IF YES, PLEASE EXPLAIN:

PLEASE CHECK SCHEDULE AVAILABILITY: [ ] I am available and desire to work FULL-TIME (40 hours), AS WELL AS OVERTIME WHEN REQUIRED, and do not have restrictions on my hours and days (SKIP A & B).

[ ] I am available and desire to work PART-TIME (complete Sections A & 8}

A. I am only available for PART-TIME because: [ ] Student [ j Other Job [ ] Other (explain)

B„ HOURS {PART-TIME A P P L I C A N T S ONLY)

AVAILABLE

FROM

TO

MON

A i P.I

A i PA

TUE

A M P.M.

A M P.M.

WED

A M P.M.

A M P.M.

THUR

A M P.M.

A M P.M.

FRI

A M P.M.

A M P.M.

SAT

A M P.M.

A M P.M.

SUN

A M P.M

A M P.M

NOTE: WORK SCHEDULES ARE BASED UPON THE NEEDS OF THE BUSINESS AND MAY BE SUBJECT TO CHANGE ON A WEEKLY BASIS.

WAGE EXPECTED DATE AVAILABLE FOR WORK?

E M P L O Y M E N T H I S T O R Y

BEGIN WITH YOUR MOST RECENT EMPLOYMENT |1] AND CONTINUE WITH ALL PAST EMPLOYMENT & MILITARY EXPERIENCE (ATTACH ADDITIONAL SHEET IF NECESSARY)

EMPLOYER F R O M STARTING J O B TITLE REASON FOR LEAVING {P lea se

1 EMPLOYER MO. YR. SALARY Explain)

NAME O F COMPANY $ D E S C R I B E YOUR JOB DUTIES

A D D R E S S T O ENDING

MO. YR. SALARY

CiTY STATE ZIP $ NAME, TITLE & P H O N E O F IMMEDIATE S U P E R V I S O R

P H O N E NO.

T Y P E O F B U S I N E S S

EXPLAIN ANY P E R I O D " B E T W E E N J O B S

MAY W E C O N T A C T E M P L O Y E R ? [ ] Y E S [ ] NO

2 EMPLOYER FROM STARTING JOB TITLE REASON FOR LEAVING ( P l e a s e 2 EMPLOYER

MO. YR. SALARY Explain)

NAME O F COMPANY $ D E S C R I B E YOUR JOB DUTIES


MO. YR. SALARY

CITY STATE ZIP $ NAME, TITLE & P H O N E O F IMMEDIATE S U P E R V I S O R

P H O N E NO.


EXPLAIN ANY P E R I O D B E T W E E N J O B S

MAY W E C O N T A C T E M P L O Y E R ? [ ] Y E S [ ] NO

EMPLOYER FROM STARTING J O B TITLE REASON FOR LEAVING ( P l e a s e o EMPLOYER MO. YR. SALARY Explain)

NAME O F COMPANY $ D E S C R I B E YOUR JOB D U T I E S


MO. YR. SALARY

CITY STATE ZIP $ NAME, TITLE & P H O N E O F IMMEDIATE S U P E R V I S O R

P H O N E NO.


EXPLAIN ANY P E R I O D B E T W E E N J O B S .

MAY W E C O N T A C T E M P L O Y E R ? [ ] Y E S [ ] N O

4 EMPLOYER F R O M STARTING JOB TITLE REASON FOR LEAVING {P lea se 4 EMPLOYER

MO. YR. SALARY Explain)

NAME O F COMPANY $ D E S C R I B E Y O U R JOB D U T I E S


MO. YR. SALARY

CITY STATE, ZIP $ NAME, TITLE & P H O N E O F IMMEDIATE S U P E R V I S O R

P H O N E NO.


EXPLAIN ANY P E R I O D B E T W E E N J O B S

MAY W E CONTACT E M P L O Y E R ? [ ] Y E S [ ] N O

EDUCATION EDUCATION

T Y P E O F S C H O O L NAME, CtTY & STATE O F S C H O O L M A J O R

S U B J E C T CIRCLE LAST

YEAR ATTENDED GRADUATED D E G R E E

HIGH S C H O O L 9 1 0 1 1 12 [ ] Y E S [ ] NO

COLLEGE 1 2 3 4 [ ] Y E S [ ] NO

GRADUATE S C H O O L 1 2 3 4 [ 1 Y E S [ 1 NO

T R A D E / B U S I N E S S / O T H E R S C H O O L 1 2 3 4 ( ] Y E S [ ] N O

CONSTRUCTION RELATED EQUIPMENT EXPERIENCE

PLACE A CHECK MARK BY EACH TYPE OF JOBS AND EQUIPMENT YOU HAVE SIGNIFICANT EXPERIENCE IN:

FRONT END LOADER VIBRATORY ROLLER DOZER OFF ROAD TRUCK FUEL TRUCK LABOR

RUBBER TIRE LOADER MOT ORGRADER TRACK BACKHOE PAN FINE GRADING TRACTOR POSI-TRAC TRACTOR TRAILER LOW BOY WATER TRUCK DUMP TRUCK OTHER: OTHER:

ADDITIONAL EXPERIENCE OR QUALIFICATIONS List a n y o t h e r e x p e r i e n c e , skills or o t h e r q u a l i f i c a t i o n s inc lud ing h o b b i e s , which y o u b e l i e v e s h o u l d b e c o n s i d e r e d in e v a l u a t i n g y o u r q u a l i f i c a t i o n s for

e m p l o y m e n t . P l e a s e ind ica t e a n y pr ior mil i tary s e r v i c e y o u w o u l d like c o n s i d e r e d in c o n n e c t i o n with y o u r a p p l i c a t i o n for e m p l o y m e n t .

ATTENDANCE AND PUNCTUALITY INFORMATION Consistent attendance and punctuality are essential requirements of every job with this company. Is there anything which would interfere with your regular attendance and punctuality if you are offered a job with the company? [ } YES [ ] NO If Yes, please explain

PROFESSIONAL/WORK-RELATED REFERENCES ( P l e a s e , n o f r i ends or r e l a t i v e s ) 1 NAME PHONE RELATIONSHIP

WHAT WILL HE/SHE SAY ABOUT YOU?

2 NAME PHONE RELATIONSHIP


3 NAME PHONE RELATIONSHIP


NOTIFICATION AND AGREEMENT

PLEASE READ B E F O R E SIGNING

I CERTIFY THAT ALL A N S W E R S GIVEN BY ME A R E TRUE, A C C U R A T E AND COMPLETE,. I UNDERSTAND THAT THE FALSIFICATION, M I S R E P R E S E N T A T I O N O R OMISSION O F FACT ON THIS APPLICATION (OR ANY OTHER ACCOMPANYING O R REQUIRED DOCUMENTS) WILL B E C A U S E F O R DENIAL O F EMPLOYMENT O R IMMEDIATE TERMINATION OF EMPLOYMENT, R E G A R D L E S S O F WHEN OR HOW DISCOVERED..

Questions regarding this s t a t e m e n t should be directed to any employment interviewer before signing The application wiii be given every consideration, but its receipt does not imply tha t the applicant wili be employed

It is the policy of the company to afford equaf opportunity to all employees and applicants for employment without regard to age, race, religion, color, sex, national origin, marital s ta tus , expunged juvenile records, or pregnancy, and to afford equal opportunities to disabled ve terans , ve terans of the Vietnam era, and individuals with a disability, any and other characteristic protected by Federal, S ta t e or Local law

I authorize the investigation of all s t a t e m e n t s and information contained in this application. I re lease from all liability anyone supplying such information and I also release the employer from ail liability t ha t might result from making an investigation

If hired, I agree to abide by all of t h e company rules and regulation, and unders tand tha t , if employed, my employment may be terminated with or without cause, and with or without notice, a t any t ime, at the option of either the company or me, I further unders tand tha t no representa t ion , whether oral or written by any representa t ive or agen t of the Company, at any time, can constitute a contract of employment I understand tha t the Company and all Plan Administrators shall have the maximum discretion permitted by law to administer , interpret, modify, discontinue, e n h a n c e or otherwise change all policies, procedures, benefi ts or other t e r m s or conditions of employment . No representat ive or agen t of the company, has the authority to enter into any agreement for employment for any specified period of t ime or to m a k e any change in any policy, procedure, benefit or other term or condition of employment other than in a document signed by t h e President or CEO, or to make any a g r e e m e n t contrary to the foregoing

I acknowledge tha t I have read and unders tand the above s t a t emen t s and hereby grant permission to confirm the information supplied on this application by me

APPLICANT SIGNATURE DATE

! Please tell us how you heard about our job opportunities. \ Current Employee (Please tell us who) ; j Newspaper Ad (Please tell us which paper and when) ; j Online Ad (Please tell us t h e websi te and when) : i Other1 (Please Explam)j _

J, E UESFELD CONTRACTOR, INC SITE PREPARATION

1855 BENNINGTON ROAD ROCKV1LLE, ViRGiNiA 2 3 1 4 6

Teh 804-749-3276 pax: 804-749-4566

m m w M T FMP1 OYEE INFORMATION AS O F . O M I h l l

Name:

Address:

Citv/State/Zip:_

Cell Phone Number:.

Maiital Status:_

Drivers License #:

S S # :

Home Phone Number

Date of Biith:

Number of Dependants:

Emergency Contact;

Department of Homeland Security U.S. Citizenship and Immigrat ion Services

OMB N o 1615-0047; Expires 08/31/12

Form 1-9, Employment Eligibility Verification

Read instr uctions car efully before completing this form T h e instructions must be available d m ing 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. T h e refusal to hire an individual because the documents have a futur e 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 5 Date of Birth (month/day/year)

City State 2\p Code Social Security #

I am aware that federal law provides for imprisonment and/or fines lot false statements or use of false documents in connection with the

I atiest. under penalty of perjury, that I am (check one of the following):

I | A citizen of the United States

| j A noncitizen national of the United States (see instructions)

completion of this form. u A lawful permanent resident (Alien #)

• An alien authorized to work (Alien # or Admission until {expiration date, ii applicable - month/day/year)

Employee's Signature Dale (month/day/year)

P r e p a r e r a n d / o r T r a n s l a t o r C e r t i f i c a t i o n (To be completed and signed if Section I is prepared by a person other than the employee) J 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 (7b be completed and signed by employer. Examine one document from L is I A OR examine one document from List B and one from List C, as Ihted on the reverse of this form, and record the title, number, and expiration date, if any; of the document(s).)

List A Document title:

Issuing authority:

Document #:

O R ListB AND ListC

Expiration Date (if any).

Document #:

Expiration Date (if any)

C E R T I F I C A T I O N : I attest, under penalty of perjury, that I have examined the d o c u m e n t 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 m y knowledge the employee is authorized to work in the United States (State employment agencies m a y 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. Updat ing 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): 1 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 documents), the documents) 1 have examined appear to be genuine and to relate to the Individual Signature of Employer or Authorized Representative Date (month/day/year)

Form 1-9 (Rev 08/07/09) Y Page 4

LISTS OF ACCEPTABLE DOCUMENTS All documents must be unexpired

LIST A LIST B LIST C

Documents that Establish Both Documents that Establish Documents that Establish Identity and Employment Identity Employment Authorization

Authorization OR AND

1.. U .S . Passport oi U S Passport Card 1- Driver's license oi ID card issued by a State ox 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

1„ Social Security Account Number car d other than one that specifies on the face that the issuance of the card does not authorize employment in the United States 2. Permanent Resident Car d or Alien

Registration Receipt Card (Form 1-551)

1- Driver's license oi ID card issued by a State ox 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

1„ Social Security Account Number car d other than one that specifies on the face that the issuance of the card does not authorize employment in the United States 2. Permanent Resident Car d or Alien

Registration Receipt Card (Form 1-551)

1- Driver's license oi ID card issued by a State ox 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.. Certification of Birth Abroad issued by the Department of State (FormFS-545) 3.. F oreign passport that contains a

temporary 1-551 stamp or temporary 1-551 printed notation on a machine-readable immigr ant visa

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

2.. Certification of Birth Abroad issued by the Department of State (FormFS-545) 3.. F oreign passport that contains a

temporary 1-551 stamp or temporary 1-551 printed notation on a machine-readable immigr ant visa

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. Certification of Report of Birth

issued by the Department of State (Form DS-1350) 4, Employment Authorization Document

that contains a photograph (Form. 1-766)

3.. Schooi ID card with a photograph

3. Certification of Report of Birth issued by the Department of State (Form DS-1350) 4, Employment Authorization Document

that contains a photograph (Form. 1-766) 4.. Voter's registration card 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.. In the case of a nonimmigrant alien author ized to work for a specific employer incident to status, a foreign passport with Form 1-94 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 oi limitations identified on the form

5„ U S Military card oi draft record

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


6,, Military dependent's ID card

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


7., U..S. Coast Guard Merchant Mariner Card

5. Native American tribal document


8„ Native American tribal document

6„ U ,S. Citizen ID Card (Form 1-197)


9, Driver's license issued by a Canadian government authority

6„ U ,S. Citizen ID Card (Form 1-197)


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

7.. Identification Car d for Use of Resident Citizen in the United States (Form 1-179)

6.. Passport from the Federated States of Micronesia (F SM) or the Republic of the Marshall Islands (RMI) with Form 1-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

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

7.. Identification Car d for Use of Resident Citizen in the United States (Form 1-179)


10.. School recor d or report card 8 Employment authorization document issued by the Department of Homeland Security


11, Clinic, doctor, or hospital record

8 Employment authorization document issued by the Department of Homeland Security

6.. Passport from the Federated States of Micronesia (F SM) or the Republic of the Marshall Islands (RMI) with Form 1-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI 12.. Day-care or nursery school record

8 Employment authorization document issued by the Department of Homeland Security

Illustrations of many of these documents appear in Par t 8 of the Handbook for Employer s (M-274) Form 2-9 (Rev 08/07/09) Y Page 5

Depar t m e n t of H o m e l a n d Secur ity U S Citizenship and Immigrat ion Services

OMB N o 1615-0047; Expires 08/31/12

Form 1-9, Employment Eligibility Verification

Instructions Read all instructions car efully before completing this form,

A n t i - D i s c r i m i n a t i o n 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 fo r a fee because of that individual's national origin or' citizenship status It is illegal to discriminate against work-authorized individuals Employers C A N N O T specify which d o c u m e n t s ) they will accept f rom 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, cail the Off ice of Special Counsel for Immigrat ion Related Unfair Employment Practices at 1-800-255-8155

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

i W h i n M i m i l t l 1 i > i i n ! <> ( s t t l '

All employees (citizens and noncitizens) hired after November 6, 1986, and working in the United States must complete Form 1-9,

I i l l n i ' j , O i i l I i n i n I - 4 )

Section 1, Employee

Ihis 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 Pr ogram (E-Verify) I h e employer is r esponsible for ensur ing that Section 1 is timely and properly completed,

Noncitizen nationals of the United States are persons born in American Samoa, certain former1 citizens of the former Irust 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

in Section 2 evidence of employment authorization that contains an expiration date (e g , Employment Authorization Document (Form 1-766)).

Preparer/Translator Certification

The Preparet/Translatoi Certification must be completed if Section 1 is prepared by a person other than the employee A preparei/tianslator 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

For the purpose of completing this form, the term "employer " means all employers including those recruiter s 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 thiee 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 Employer s cannot specify which document(s) listed on the last page of Form 1-9 employees present to establish identity and employment authorization Employees may present any List A document O R a combination of a List B and a List C document.

If an employee is unable to pr esent 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..

Employers must record in Section 2:

1. Document title; 2„ Issuing authority; 3., Document number; 4., Expiration date, if any; and 5, 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 documents) presented If photocopies are made, they must be made for ail new hires. Photocopies may only be used for the verification process and must be retained with Form 1-9. Employers are still responsible for completing and r etaining Form 1-9.

Form 1-9 (Rev 08/07/09) Y

For more detailed information, you may refer to the USCIS Handbook for Employers (Form M-274). You may obtain the handbook using the contact infor mation found under the header "USCIS Forms and Information "

Section 3, Updating and Reverification

Employers must complete Section 3 when updating and/or reverifying Form 1-9. Employers must revetify 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 wiii 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 or1 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 L ist 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 1-9 instead of completing Section 3,.

W I K i t K IIk1 I 11 mil I ui"*'

There is no associated filing fee for completing Porm 1-9 This form is not filed with USCIS or any government agency. Form 1-9 must be retained by the employer and made available for inspection by U.S. Government officials as specified in the Privacy Act Notice below..

IJSCiS Forms and Information

Io 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 1-9 from our website at www uscis gov or by calling 1-888-464-4218

Information about E-Veiify, a free and voluntary program that allows participating employers to electronically verify the employment eligibility of their newly hired employees, can be obtained fiom our website at www uscis .gov/e-verify or by calling 1-888-464-4218.

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 out Internet website at www. uscis gov

Photocopying and Retaining Form T-9

A blank Form 1-9 may be reproduced, provided both sides ate copied The Instructions must be available to all employees completing this form. Employers must letain completed Form I-9s for three years after the date of hire or one year after the date employment ends, whichever is later.

Form 1-9 may be signed and retained electronically, as authorized in Department of Homeland Security regulations at 8 CFR 274a.2.

I r U l N n l i t t

I he authority for collecting this information is the Immigration Reform and Control Act of 1986, Pub. 1... 99-603 (8 USC 1324a)

This information is foi employers to verify the eligibility of individuals for employment to preclude the unlawful hiiing, ot recruiting or refening 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. Ihe 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

E M P L O Y E R S MUST RETAIN C O M P L E T E D F O R M 1-9 F o r m l ' 9 (R e v 08/07/09) Y Page 2 D O NOT M A I L COMPLETED F O R M 1-9 T O ICE O R USCIS

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 r egar ding this bur den 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 1615-004 7. Do not mail yom completed Form 1-9 to this address,

Form 1-9 (Rev 08/07/09) Y Page 3

Form W-4 ( 2 0 0 4 ) Purpose . Complete Form W-4 so that your employer can withhold the correct Federal income tax from your pay Because your tax sit-uation may change, you may want to rerigure your withholding each year. E x e m p t i o n from wi thholding if you a r e exempt , complete only lines 1, 2 3, 4, and 7 a n d sign the form to validate it. Your exemption for 2004 expires February 16, 2005 S e e P u b 505 Tax Withholding and Estimated Tax. Note: You cannot claim exemption from with-holding if: (a) your income exceeds S8Q0 and includes more than $250 of unearned income (e.g.. interest and dividends) and (b) another person can claim you as a dependent on their tax return. Bas ic instructions. If you are not exempt, c o m -plete t he Personal Al lowances Worksheet below. The workshee ts on page 2 adjust your withholding allowances based on itemized

deduct ions certain credits , a d j u s t m e n t s to income, or iwo-eamer / iwo- jcb situations. Com-plete al! workshee t s that apply . H o w e v e r you may claim f e w e r (or zero) a l l o w a n c e s . H e a d of h o u s e h o l d Generally, you may claim head of household filing s t a t u s on your tax return only if you are unmarried and pay more than 5 0 % of the c o s t s of keeping u p a h o m e for yourself and yGur d e p e n d e n t s ) or other qualify-ing individuals. S e e line E be iow. Tax credits. You can take projec ted tax credi ts into accoun t in figuring your al lowable number of withholding allowances. Credi ts for child or dependen t c a r e e x p e n s e s a n d the child tax credit may be claimed us ing the Persona! Al lowances Worksheet be iow. S e e Pub. 919, How Do I Adjust My Tax Withholding? for infor-mation on converting your other credi ts into withholding allowances. N o n w a g e i n c o m e if you h a v e a large amoun t of nonwage income such a s interest or dividends, consider making est imated tax p a y m e n t s using

Form 1040-ES Estimated Tax for Individuals Otherwise you may owe additional tax Two earners/ two j o b s . If you have a working s p o u s e or more than one j o b figure the total number of al lowances you are entitled to claim on al! j o b s using workshee t s from only o n e Form W-4 Your withholding usually will be most accu -rate when all a l lowances are claimed on the Form W-4 for the highest paying j o b and zero allowances are claimed on the others Nonresident alien. If you are a nonresident alien, s e e the Instructions for Form 8233 before completing this Form W-4

Check your withholding. After your Form W-4 lakes effect, use Pub. 919 to s e e how the dollar amount you are having withheld c o m p a r e s to your projected total tax for 2004. S e e Pub 919, especially if your earnings exceed $125 000 (Single) or $175,000 (Married). Recent name c h a n g e ? If your name on line 1 differs from that shown on your social security card., call 1 -800-772-1213 to initiate a n a m e change and obtain a social security card show-ing your correct n a m e

Personal A l lowances Worksheet (Keep for your records.)

1 A E n t e r "1" for y o u r s e l f if n o o n e e l s e c a n c l a i m y o u a s a d e p e n d e n t

(» Y o u a r e s i n g l e a n d h a v e only o n e j o b ; o r

• You a r e m a r r i e d h a v e only o n e j o b a n d y o u r s p o u s e d o e s n o t w o r k ; or

• Your w a g e s f rom a s e c o n d j o b or your s p o u s e s w a g e s (or t h e to ta l of both) a r e $1 0 0 0 or l e s s

C E n t e r 1 fo r y o u r s p o u s e . But . y o u m a y c h o o s e t o e n t e r -0 - if y o u a r e m a r r i e d a n d h a v e e i t h e r a w o r k i n g s p o u s e o r

m o r e t h a n o n e j o b (Enter ing ' " -0 - ' m a y h e l p y o u a v o i d h a v i n g t o o lit t le t a x w i t h h e l d )

D E n t e r n u m b e r of d e p e n d e n t s (o ther t h a n y o u r s p o u s e o r you r se l f ) y o u wit! c l a i m o n y o u r t a x r e t u r n

E E n t e r 1 if y o u wiil file a s h e a d o f h o u s e h o l d o n y o u r t ax r e t u r n ( s e e c o n d i t i o n s u n d e r H e a d o f h o u s e h o l d a b o v e )

F E n t e r 1 if y o u h a v e a t l e a s t $1 5 0 0 of c h i l d o r d e p e n d e n t c a r e e x p e n s e s f o r w h i c h y o u p l a n t o c l a i m a c r e d i t . .

( N o t e : Do not include child support payments See Pub. 503, Child and Dependent Care Expenses., for details.)

G C h i l d T a x C r e d i t ( including a d d i t i o n a l ch i ld tax credi t ) : • If y o u r to ta l i n c o m e wiil b e l e s s t h a n $ 5 2 0 0 0 ( $ 7 7 , 0 0 0 if mar r i ed ) , e n t e r 2 f o r e a c h el igible chi ld • If y o u r to ta l i n c o m e will b e b e t w e e n $ 5 2 0 0 0 a n d $ 8 4 0 0 0 ($77 0 0 0 a n d $ 1 1 9 0 0 0 if m a r r i e d ) e n t e r 1 fo r e a c h el igible ch i ld p l u s " 1 ' a d d i t i o n a l if y o u h a v e f o u r o r m o r e e l ig ib le c h i l d r e n

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 >• For a c c u r a c y c o m p l e t e all w o r k s h e e t s t h a t app ly

If y o u p l a n t o i t e m i z e o r c l a i m a d j u s t m e n t s t o i n c o m e a n d w a n t t o r e d u c e y o u r w i t h h o l d i n g s e e t h e D e d u c t i o n s a n d A d j u s t m e n t s W o r k s h e e t o n p a g e 2.

• if you have more than o n e j o b or are married and y o u a n d your s p o u s e both work and the combined earnings from all j o b s exceed $35 000 ($25 000 if married) s e e the Two-Earner /Two-Job Worksheet on p a g e 2 to avoid having too little tax withheld

• If n e i t h e r of t h e a b o v e s i t u a t i o n s a p p l i e s , s t o p h e r e a n d e n t e r t h e n u m b e r f r o m line H o n l ine 5 of F o r m W - 4 b e l o w .

Form W-4 Depar tment of the Treasury Internal Revenue Service

Cut h e r e a n d g i v e Form W-4 t o y o u r e m p l o y e r . K e e p t h e t o p part for your r e c o r d s

Employee's Withholding Allowance Certificate • Your employer must send a copy of this form to the IRS if: (a) you claim more than

10 allowances or (b) you claim "Exempt" and your w a g e s are normally more than $200 per week.

OMB No 1545 0010

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 CU Married IZ3 Married, but withhold at higher Single rate. Note:# married, but legally separated, or spouse is s nonresident alien, check the 'Single'box.

City or town state and ZIP code 4 -if your iast name differs from that shown on your social security

card, c h e c k here. You must call 1-800-772-1213 for a new card. D

5 Tota l n u m b e r of a i i o w a n c e s y o u a r e c l a i m i n g ( f rom line H a b o v e o r f r o m t h e a p p l i c a b l e w o r k s h e e t o n p a g e 2)

6 A d d i t i o n a l a m o u n t if a n y . y o u w a n t w i t h h e l d f r o m e a c h p a y c h e c k

7 I c l a i m e x e m p t i o n f r o m w i t h h o l d i n g f o r 2 0 0 4 . a n d ! c e r t i f y t h a t I m e e t b o t h o f t h e fo l lowing c o n d i t i o n s fo r e x e m p t i o n :

• L a s t y e a r I h a d a r igh t t o a r e f u n d of all F e d e r a l i n c o m e t a x w i t h h e l d b e c a u s e I h a d n o t a x liability a n d • T h i s y e a r i e x p e c t a r e f u n d of al l F e d e r a l i n c o m e t a x w i t h h e l d b e c a u s e I e x p e c t t o h a v e n o t a x liability,

If y o u m e e t b o t h c o n d i t i o n s , w r i t e E x e m p t h e r e j 7 I Under penalties of perjury I certify that I am entitled to the number of withholding allowances ciaimed on this certificate or I am entitled to claim exempt status E m p l o y e e ' s s i g n a t u r e (Form is no t valid unless you sign it.) • D a t e •

m

8 Employer's name and address (Employer; Complete lines 3 and 10 only if sending to the IRS) Office code (optional)

10 Employer identification number (EIN)

For Pr ivacy Act a n d P a p e r w o r k R e d u c t i o n Act N o t i c e , s e e p a g e 2 SELECTFORM INC Box 3045 Freeport NY 11520 Tel: 800-326-0311

Cat No 10220Q Form W - 4 (2004)

Form W-4 (2004) Page 2

Deductions and Adjustments Worksheet

Ente r :

N o t e : Use this worksheet only if you plan to itemize deductions, claim certain credits., or claim adjustments to income on your 2004 tax return 1 E n t e r an e s t i m a t e of y o u r 2 0 0 4 i t e m i z e d d e d u c t i o n s T h e s e i n c i u d e q u a l i f y i n g h o m e m o r t g a g e in t e r e s t ,

c h a r i t a b l e c o n t r i b u t i o n s , s t a t e a n d loca l t a x e s , m e d i c a l e x p e n s e s in e x c e s s o f 7 5 % of your i n c o m e , a n d m i s c e l l a n e o u s d e d u c t i o n s (For 2 0 0 4 , y o u m a y h a v e t o r e d u c e y o u r i t e m i z e d d e d u c t i o n s if y o u r i n c o m e is o v e r $ 1 4 2 7 0 0 ($71 3 5 0 if mar r i ed filing s e p a r a t e l y ) S e e W o r k s h e e t 3 in P u b 9 1 9 fo r d e t a i l s ) 1 J

$ 9 7 0 0 if m a r r i e d filing jo in t ly o r qua l i fy ing w idow(e r )

5 7 1 5 0 if h e a d of h o u s e h o l d

$ 4 8 5 0 if s i n g l e

$ 4 8 5 0 if m a r r i e d filing s e p a r a t e l y

3 S u b t r a c t l ine 2 f r o m line 1 If line 2 is g r e a t e r t h a n l ine 1 e n t e r - 0 - ' . . .. . 3

4 Enter an estimate of your 2004 adjustments to income including alimony deductible IRA contributions and student loan interest 4

5 A d d l ines 3 a n d 4 a n d e n t e r t h e to ta l ( Inc lude a n y a m o u n t for c r e d i t s f r o m W o r k s h e e t 7 in P u b 919) .. 5

6 En te r a n e s t i m a t e of y o u r 2 0 0 4 n o n w a g e i n c o m e ( s u c h a s d i v i d e n d s or i n t e r e s t ) . . . . . . . . 6

7 S u b t r a c t line 6 from line 5 Enter the result but not less t h a n - 0 - . . . . . .. 7

8 D i v i d e t h e a m o u n t on line 7 by $3 0 0 0 a n d e n t e r t h e r e s u i t h e r e D r o p a n y f r a c t i o n . . . 8

9 En t e r the n u m b e r f r o m the P e r s o n a l A l l o w a n c e s W o r k s h e e t , l ine H p a g e 1 . . . 9

1 0 A d d l ines 8 a n d 9 a n d e n t e r t h e tota l h e r e If y o u p l a n t o u s e d i e T w o - E a r n e r / T w o - J o b W o r k s h e e t , a l s o e n t e r t h i s t o t a l o n line 1 b e l o w . O t h e r w i s e , s t o p h e r e a n d e n t e r t h i s to ta l o n F o r m W - 4 , l ine 5. p a g e 1 . 1 0

Two-Lamer/two-Job Worksheet (See Two earners/two jobs on page 1.) N o t e : Use this worksheet only if the instructions under line H on page ? direct you here

1 Enter the number from line H p a g e 1 (or from line 10 above if you used the Deduct ions and Adjustments Worksheet)

2 F ind t h e n u m b e r in T a b l e 1 b e l o w t h a t a p p l i e s t o t h e L O W E S T p a y i n g j o b a n d e n t e r it h e r e

3 If l ine 1 is m o r e t h a n o r e q u a l t o l ine 2, s u b t r a c t l ine 2 f r o m l ine 1 E n t e r t h e r e s u l t h e r e (if z e r o e n t e r " -Q- ') a n d o n F o r m W - 4 l ine 5 p a g e 1 D o n o t u s e t h e r e s t of t h i s w o r k s h e e t

N o t e : If line 1 is less than line 2, enter -0• on Form W-4 Sine 5, page I Complete lines 4-9 below to calculate the additional withholding a m o u n t necessary to avoid a year-end tax bill

Ente r t h e n u m b e r f rom line 2 of t h i s w o r k s h e e t 4

E n t e r t he n u m b e r f rom l ine 1 of th i s w o r k s h e e t 5

S u b t r a c t l ine 5 f r o m line A . . . . . . . . . . . . . .

Find t h e a m o u n t in T a b l e 2 b e l o w t h a t a p p l i e s t o t h e HIGHEST p a y i n g j o b a n d e n t e r it h e r e . . . Mult iply Ijne 7 by line 6 a n d e n t e r t h e r e s u l t h e r e T h i s is t h e a d d i t i o n a l a n n u a l w i t h h o l d i n g n e e d e d Div ide l ine 8 b y t h e n u m b e r of p a y p e r i o d s r e m a i n i n g in 2 0 0 4 . For e x a m p l e d i v i d e b y 2 6 if y o u a r e p a i d e v e r y t w o w e e k s a n d y o u c o m p l e t e t h i s f o r m in D e c e m b e r 2 0 0 3 En te r t h e r e s u i t h e r e a n d o n F o r m W - 4 l ine 6, p a g e 1 . T h i s i s - the a d d i t i o n a l a m o u n t t o b e w i t h h e l d f r o m e a c h p a y c h e c k . . . . . . . .

Table 1: Two-Earner/Two-Job Worksheet Married Filing Jointly Married Filing Jointly All O t h e r s

If wages from HIGHEST paying job are—

AND, wages from LOWEST paying job are—

Enter on line 2 above

if wages from HIGHEST paying job are—

AND, wages ircm LOWEST paying job are—


II wages from LOWEST paying job are—


$0 •• $40 000 $0 - S4.000 4 001 - 8 000 8 001 • 17,000

17,001 and over

0 1 2 3

S40 001 and over 31 001 - 38 000 38 001 - 44 000 44 001 - 50 000 50 001 - 55 000 55 001 - 65 000 65 001 •• 75 000 75 001 - 85 000 85 COt - 100000

100001 - 115,000 115001 and over

6 7 6 9

10 11 12 13 14 15

SO - S6 000 6 001 - 11 000

11 001 18 000 18 001 • 25 000 25 001 - 31 000 31 001 - 44 000 44 001 55 000 55 001 - 70 000 70 001 - 80,000 80 001 - 100,000

100,001 and over

0 1 2 3 4 5 6 7 8 9

10

$40 001 and over $0 54,000 4 001 3 000 8 0 0 1 - 1S000

15.001 - 22 000 22 001 - 25 000 25,001 - 31,000

0 1 2 3 4 5

S40 001 and over 31 001 - 38 000 38 001 - 44 000 44 001 - 50 000 50 001 - 55 000 55 001 - 65 000 65 001 •• 75 000 75 001 - 85 000 85 COt - 100000

100001 - 115,000 115001 and over

6 7 6 9

10 11 12 13 14 15

SO - S6 000 6 001 - 11 000

11 001 18 000 18 001 • 25 000 25 001 - 31 000 31 001 - 44 000 44 001 55 000 55 001 - 70 000 70 001 - 80,000 80 001 - 100,000

100,001 and over

0 1 2 3 4 5 6 7 8 9

10

Table 2: Two-Earner/Two-Job Worksheet Married Filing Joint ly All O t h e r s

If wages from HIGHEST Enter on If wages from HIGHEST Enter on paying j o b are— line 7 above paying job are— line 7 above

SO - $60 000 £470 $0 S30 000 $470 60 001 - 110.000 780 30 001 70 000 780

110.001 - 150 000 870 70 001 140 000 870 150 001 - 270,000 1 020 140 001 320,000 1 020 270,001 and over 1,090 320,001 and over 1.090

Privacy A c t and Paperwork Reduction Act Notice. W e a s k for the information on this form t o carry out t h e Internal Revenue, l aws of t h e United Sta tes . T h e interna! Revenue C o d e requires th i s information under s ec t ions 3402(f)(2)(A) a n d 6 1 0 9 a n d their regulations. Failure to provide a properly c o m p l e t e d form will resui t in your b e i n g t rea ted a s a s i n g l e person w h o c l a i m s n o withholding a l l o w a n c e s ; providing fraudulent information may a l s o subjec t y o u t o penalt ies . Rout ine u s e s of this information inc lude giving it to the Depar tment of J u s t i c e for civil a n d criminal litigation, t o cities, s t a t e s , and the District of Columbia for u s e in adminis ter ing their tax laws, and using it in t h e National Directory of New Hires. W e may a l so d i sc lose this information to Federa l and s t a t e a g e n c i e s to e n f o r c e Federal nontax criminal laws and t o c o m b a t terrorism

You are not required to provide the information r e q u e s t e d on a form tha t is sub jec t to the Paperwork Reduction Act un le s s the form displays a valid Q M S

control n u m b e r . B o o k s o r r e c o r d s relating to a form or i ts ins t ruct ions m u s t be re ta ined a s long a s their c o n t e n t s may b e c o m e material in the administrat ion of any internal .Revenue law Generally, t a x re turns a n d return information a re confidential , a s requi red b y C o d e sec t ion 6 1 0 3

The t ime n e e d e d to c o m p l e t e this form will vary depend ing on individual c i r c u m s t a n c e s The e s t ima ted ave rage time is: R e c o r d k e e p i n g , 4 6 min : Learning a b o u t t h e l a w or the form, 13 min.; Preparing t h e form, .59 min. If you have comments concerning t h e accuracy of t h e s e t ime es t imates or s u g g e s t i o n s for making this form simpler, w e would b e happy to hea r from you. You can write t o t h e Tax P r o d u c t s Coordinat ing Commit tee . Wes te rn Area Distribution Center . R a n c h o Cordova , CA 9 5 7 4 3 - 0 0 0 1 . D o n o t s e n d Form W-4 to this a d d r e s s ins tead give it to your emp loye r