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SAMPLE NOTE – WE WILL ALTER THIS TO READ HOWEVER YOU LIKE

Please take your time and complete all fields CORRECTLY.
You WILL NOT be permitted to begin work until these documents are completed correctly.
DO IT RIGHT, OR DO IT TWICE!

Consent to Reference and Background Check

I, (Your Name Will Be Populated Here) hereby authorize:

BUSINESS NAME (the “Company”) of BUSINESS ADDRESS, and/or its agents to make investigation of my background, references, character, past employment, consumer reports, education, and criminal history record information which may be in any state or local files, including those maintained by both public and private organizations, and all public records, for the purpose of confirming the information contained on my application and/or obtaining other information which may be material to my qualifications for employment. A telephone facsimile (fax) or xerographic copy of this consent shall be considered as valid as the original consent.

I hereby consent to the Company’s verification of all the information I have provided on my application form. I also agree to execute as a condition of employment or a condition of continued employment any additional written authorization necessary for the Company to obtain access to and copies of records pertaining to this information. I also hereby authorize the Company’s access to any medical histories or records pertaining to me (and any other individuals who due to my employment may be covered by any Company medical or other insurance program). With regard to the foregoing disclosures, I hereby agree to release any person, company, or other entity from any and all causes of action that otherwise might arise from supplying the Company with information it may request pursuant to this release. I understand that any false answers or statements, or misrepresentations by omission, made by me on this application or any related document, will be sufficient for rejection of my application or for my immediate discharge should such falsifications or misrepresentations be discovered after I am employed.

Background Check Authorization Signature(Required)

I understand and agree this is a legal representation of my signature.

Work Start Date(Required)

What is your scheduled start date? This would be the first day you will work for Western Omelette Restaurant.

Date of Birth(Required)

First Name(Required)

Middle Initial

Please RE-ENTER your middle initial only

Last Name(Required)

Other Last Names Used (if any)

Phone(Required)

Email(Required)

Please enter the email address you would like the sample forms emailed too.

Address(Required)

Apartment or Unit Number

City of Residence(Required)

State(Required)

Zip Code(Required)

Marital Status(Required)

Spouse's Name(Required)

Spouse's Cell Phone Number(Required)

Do you have an emergency contact(Required)

Yes

No

Emergency Contact Last Name(Required)

Emergency Contact First Name(Required)

Emergency Contact Address(Required)

Emergency Contact Relationship(Required)

Emergency Contact Cell Phone Number(Required)

Personal Documents

The documents attached will be used for identity confirmation purposes, and may be used to report work status to government agencies.

Acceptable Image / File (If taking a photo of your Identification Documents, turn your phone HORIZONTAL and FILL THE ENTIRE IMAGE AREA) USE A SOLID BACKGROUND

Good Drivers License

🛑 STOP 🛑

Unacceptable Images / Files (Your onboarding documents will be REJECTED and you will have to complete them again, CORRECTLY, prior to starting work) The image does not fill the frame, or is in the vertical format UNACCEPTABLE!

Bad Drivers License

THESE IMAGES ARE UNACCEPTABLE! DO NOT SUBMIT YOUR IMAGES IF THEY LOOKS LIKE THIS. DO NOT SUBMIT IMAGES IN THE VERTICAL FORMAT! YOUR IMAGES MUST BE HORIZONTAL AND FILL THE ENTIRE AREA.

Drivers License, ID or Passport ID(Required)

Max. file size: 256 MB.

Please select a clear photo, scan or original document to upload. Do it right, or do it twice!

Please Enter The License / ID Number in the Photo(Required)

Please be sure to enter all characters

Please use the same acceptable Image / File example above for your Social Security Card

Social Security Card(Required)

Max. file size: 256 MB.

Please select a clear photo, scan or original document to upload. Do it right, or do it twice!
We do NOT hire without proof of your Social Security Number.

▶ Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. ▶ Your withholding is subject to review by the IRS.

▶ Does your name match the name on your social security card? If not, to ensure you get credit for your earnings, contact SSA at 800-772-1213 or go to www.ssa.gov.

First 3 Number of Social Security(Required)

Middle 2 Number of Social Security(Required)

Last 4 Number of Social Security(Required)

Select One

Filing Status(Required)

Single or Married filing separately

Married filing jointly (or Qualifying Widow(er))

Head of household (Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)

Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can claim exemption from withholding, when to use the online estimator, and privacy.

Step 2: Multiple Jobs or Spouse Works

Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse also works. The correct amount of withholding depends on income earned from all of these jobs. Do only one of the following.

(a) Use the estimator at www.irs.gov/W4App (Link Located Below) for most accurate withholding for this step (and Steps 3–4); or

(b) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding; or

(c) If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld . . . . . ▶

Please check if this applies to you.

TIP: To be accurate, submit a 2020 Form W-4 for all other jobs. If you (or your spouse) have self-employment income, including as an independent contractor, use the estimator.

Page 2, 3 and 4 of W4 (Please click the page you wish to view) You can also access the Tax Withholding Estimator by clicking the last link below.

IRS W4-Page 1 (For Reference Only)

IRS W4-Page 2 General Instructions

IRS W4-Page 3 Multiple Jobs Worksheet

IRS W4-Page 4 Calculations Sheet

IRS Tax Withholding Estimator

Complete Steps 3–4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3–4(b) on the Form W-4 for the highest paying job.)

Step 3: Claim Dependents

If your income will be $200,000 or less ($400,000 or less if married filing jointly):

Multiply the number of qualifying children under age 17 by $2,000 ▶

Multiply the number of other dependents by $500 . . . . ▶

Total . . . . . . . . . . . . .

Step 4 (optional): Other Adjustments

(a) Other income (not from jobs). If you want tax withheld for other income you expect this year that won’t have withholding, enter the amount of other income here. This may include interest, dividends, and retirement income

(b) Deductions. If you expect to claim deductions other than the standard deduction and want to reduce your withholding, use the Deductions Worksheet on page 3 and enter the result here

(c) Extra withholding. Enter any additional tax you want withheld each pay period

Step 5 (This is the signature area.) You will sign on the last page.

I9 Employment Eligibility Verification

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.

I attest, under penalty of perjury, that I am (check one of the following boxes):

1. A citizen of the United States

X (A citizen of the United States)

2. A noncitizen national of the United States (See instructions)

X 2. A noncitizen national of the United States (See instructions)

3. A lawful permanent resident

X (A lawful permanent resident)

Alien Registration Number/USCIS Number:(Required)

4. An alien authorized to work

X (An alien authorized to work)

Expiration date, if applicable, mm/dd/yyyy(Required)

Some aliens may write “N/A” in the expiration date field. (See instructions)

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

1. Alien Registration Number/USCIS Number:

OR 2. Form I-94 Admission Number:

OR 3. Foreign Passport Number:

Country of Issuance:

Employee Signature(Required)

Preparer and/or Translator Certification (check one):

(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)

I did not use a preparer or translator.

X (I did not use a preparer or translator.)

A preparer(s) and/or translator(s) assisted the employee in completing Section 1.

X ( A preparer(s) and/or translator(s) assisted the employee in completing Section 1.)

Date Prepared(Required)

Preparer Last Name(Required)

Preparer First Name(Required)

Preparer Street Address(Required)

Preparer City(Required)

Preparer State(Required)

Preparer Zip Code(Required)

Signature of Preparer or Translator(Required)

THIS IS A SIGNATURE BOX FOR PREPARER, OR TRANSLATOR. (EMPLOYEE’S DO NOT SIGN HERE.)

Employment Information

Job Title(Required)

For what position were you hired?

Department(Required)

Starting Wage / Salary (Must Be Confirmed)(Required)

If the hiring manager has not discussed your starting wage, please ask them for this information before continuing.

Supervisor / Manager(Required)

Direct Deposit Authorization

We do not issue paper checks, or pay by cash. If you do not have a bank account, Chime is a simple option. You will need this information prior to beginning work. https://www.chime.com/

I authorize my employer to send credit entries (and appropriate debit and adjustment entries), electronically or by any other commercially accepted method, to my account(s) indicated above and to other accounts I identify in the future. This authorizes the financial institution holding the Account to post all such entries. I agree that the ACH transactions authorized herein shall comply with all applicable U.S. Law. This authorization will be in effect until the Company receives a written termination notice from myself and has a reasonable opportunity to act on it.(Required)

By checking this box, I give my authorization for direct deposit

Bank Name – Primary(Required)

Is this account Checking or Savings?(Required)

Checking

Savings

Please be certain you are selecting the correct account type. If you select the incorrect account type, your pay will be rejected by your financial institution and will be delayed up to 5 days.

Routing Number – Primary(Required)

Account Number – Primary(Required)

Re-Enter Account Number – Primary(Required)

Image of your Primary account information(Required)

Max. file size: 2 MB.

This must be from your financial institution… DO NOT SUMBIT HANDWRITTEN INFORMATION! Please center your document in the frame of your screen prior to taking the photo. Photo should fill the entire screen, and be clear.

Do you want to use a second account?(Required)

Yes

No

Bank Name – Secondary(Required)

Amount or percentage to be deposited in PRIMARY account?(Required)

Is this account Checking or Savings?

Checking

Savings

Please be certain you are selecting the correct account type. If you select the incorrect account type, your pay will be rejected by your financial institution and will be delayed up to 5 days.

Routing Number – Secondary(Required)

Account Number – Secondary(Required)

Re-Enter Account Number – Secondary(Required)

Photo of Account Information (MUST INCLUDE ROUTING AND ACCOUNT NUMBER)(Required)

Max. file size: 2 MB.

This must be from your financial institution… DO NOT SUMBIT HANDWRITTEN INFORMATION! Please center your document in the frame of your screen prior to taking the photo. Photo should fill the entire screen, and be clear.

NDA Non-Disclosure Agreement

The purpose of this form is to protect company trade secrets.

This Non-disclosure Agreement (this “Agreement”) is made effective as of __________________ (the “Effective Date”), by and between BUSINESS NAME (the “Owner”), of BUSINESS ADDRESS,

and Employee (the “Recipient”), of ______________________________________.,

___________________________________________, _______ _______________.

TRADE SECRETS

The Owner has requested and the Recipient agrees that the Recipient will protect the confidential material and information which may be disclosed between the Owner and the Recipient. Therefore, the parties agree as follows:

I. CONFIDENTIAL INFORMATION. The term “Confidential Information” means any information or material which is proprietary to the Owner, whether or not owned or developed by the Owner, which is not generally known other than by the Owner, and which the Recipient may obtain through any direct or indirect contact with the Owner. Regardless of whether specifically identified as confidential or proprietary, Confidential Information shall include any information provided by the Owner concerning the business, technology and information of the Owner and any third party with which the Owner deals, including, without limitation, business records and plans, trade secrets, technical data, product ideas, contracts, financial information, pricing structure, discounts, computer programs and listings, source code and/or object code, copyrights and intellectual property, inventions, sales leads, strategic alliances, partners, and customer and client lists. The nature of the information and the manner of disclosure are such that a reasonable person would understand it to be confidential.

A. “Confidential Information” does not include:
– matters of public knowledge that result from disclosure by the Owner;
– information rightfully received by the Recipient from a third party without a duty of confidentiality;
– information independently developed by the Recipient;
– information disclosed by operation of law;
– information disclosed by the Recipient with the prior written consent of the Owner; and any other information that both parties agree in writing is not confidential.

II. PROTECTION OF CONFIDENTIAL INFORMATION. The Recipient understands and acknowledges that the Confidential Information has been developed or obtained by the Owner by the investment of significant time, effort and expense, and that the Confidential Information is a valuable, special and unique asset of the Owner which provides the Owner with a significant competitive advantage, and needs to be protected from improper disclosure. In consideration for the receipt by the Recipient of the Confidential Information, the Recipient agrees as follows:

A. No Disclosure. The Recipient will hold the Confidential Information in confidence and will not disclose the Confidential Information to any person or entity without the prior written consent of the Owner.

B. No Copying/Modifying. The Recipient will not copy or modify any Confidential Information without the prior written consent of the Owner.

C. Unauthorized Use. The Recipient shall promptly advise the Owner if the Recipient becomes aware of any possible unauthorized disclosure or use of the Confidential Information.

D. Application to Employees. The Recipient shall not disclose any Confidential Information to any employees of the Recipient, except those employees who are required to have the Confidential Information in order to perform their job duties in connection with the limited purposes of this Agreement. Each permitted employee to whom Confidential Information is disclosed shall sign a non-disclosure agreement substantially the same as this Agreement at the request of the Owner.

III. UNAUTHORIZED DISCLOSURE OF INFORMATION – INJUNCTION. If it appears that the Recipient has disclosed (or has threatened to disclose) Confidential Information in violation of this Agreement, the Owner shall be entitled to an injunction to restrain the Recipient from disclosing the Confidential Information in whole or in part. The Owner shall not be prohibited by this provision from pursuing other remedies, including a claim for losses and damages.

IV. NON-CIRCUMVENTION. For a period of five (5) years after the end of the term of this Agreement, the Recipient will not attempt to do business with, or otherwise solicit any business contacts found or otherwise referred by Owner to Recipient for the purpose of circumventing, the result of which shall be to prevent the Owner from realizing or recognizing a profit, fees, or otherwise, without the specific written approval of the Owner. If such circumvention shall occur the Owner shall be entitled to any commissions due pursuant to this Agreement or relating to such transaction.

V. RETURN OF CONFIDENTIAL INFORMATION. Upon the written request of the Owner, the Recipient shall return to the Owner all written materials containing the Confidential Information. The Recipient shall also deliver to the Owner written statements signed by the Recipient certifying that all materials have been returned within five (5) days of receipt of the request.

VI. RELATIONSHIP OF PARTIES. Neither party has an obligation under this Agreement to purchase any service or item from the other party, or commercially offer any products using or incorporating the Confidential Information. This Agreement does not create any agency, partnership, or joint venture.

VII. NO WARRANTY. The Recipient acknowledges and agrees that the Confidential Information is provided on an “AS IS” basis. THE OWNER MAKES NO WARRANTIES, EXPRESS OR IMPLIED, WITH RESPECT TO THE CONFIDENTIAL INFORMATION AND HEREBY EXPRESSLY DISCLAIMS ANY AND ALL IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE. IN NO EVENT SHALL THE OWNER BE LIABLE FOR ANY DIRECT, INDIRECT, SPECIAL, OR CONSEQUENTIAL DAMAGES IN CONNECTION WITH OR ARISING OUT OF THE PERFORMANCE OR USE OF ANY PORTION OF THE CONFIDENTIAL INFORMATION. The Owner does not represent or warrant that any product or business plans disclosed to the Recipient will be marketed or carried out as disclosed, or at all. Any actions taken by the Recipient in response to the disclosure of the Confidential Information shall be solely at the risk of the Recipient.

VIII. LIMITED LICENSE TO USE. The Recipient shall not acquire any intellectual property rights under this Agreement except the limited right to use as set forth above. The Recipient acknowledges that, as between the Owner and the Recipient, the Confidential Information and all related copyrights and other intellectual property rights, are (and at all times will be) the property of the Owner, even if suggestions, comments, and/or ideas made by the Recipient are incorporated into the Confidential Information or related materials during the period of this Agreement.

IX. INDEMNITY. Each party agrees to defend, indemnify, and hold harmless the other party and its officers, directors, agents, affiliates, distributors, representatives, and employees from any and all third party claims, demands, liabilities, costs and expenses, including reasonable attorney’s fees, costs and expenses resulting from the indemnifying party’s material breach of any duty, representation, or warranty under this Agreement.

X. ATTORNEY’S FEES. In any legal action between the parties concerning this Agreement, the prevailing party shall be entitled to recover reasonable attorney’s fees and costs.

XI. TERM. The obligations of this Agreement shall survive indefinitely from the Effective Date or until the Owner sends the Recipient written notice releasing the Recipient from this Agreement. After that, the Recipient must continue to protect the Confidential Information that was received during the term of this Agreement from unauthorized use or disclosure indefinitely.

XII. GENERAL PROVISIONS. This Agreement sets forth the entire understanding of the parties regarding confidentiality. Any amendments must be in writing and signed by both parties. This Agreement shall be construed under the laws of the State of Colorado. This Agreement shall not be assignable by either party. Neither party may delegate its duties under this Agreement without the prior written consent of the other party. The confidentiality provisions of this Agreement shall remain in full force and effect at all times in accordance with the term of this Agreement. If any provision of this Agreement is held to be invalid, illegal or unenforceable, the remaining portions of this Agreement shall remain in full force and effect and construed so as to best effectuate the original intent and purpose of this Agreement.

XIII. WHISTLEBLOWER PROTECTION. This Agreement is in compliance with the Defend Trade Secrets Act and provides civil or criminal immunity to any individual for the disclosure of trade secrets: (i) made in confidence to a federal, state, or local government official, or to an attorney when the disclosure is to report suspected violations of the law; or (ii) in a complaint or other document filed in a lawsuit if made under seal.

XIV. SIGNATORIES. This Agreement shall be executed by OWNER/MEMBER NAME, Member, on behalf of BUSINESS NAME and Employee and delivered in the manner prescribed by law as of the date first written above.

NDA Signature(Required)

This document requires a separate signature

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