Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My Public Portal
About
PRR 14-0939
You ori_tral reaue -t. dated Jame ?. 1014. is reproduced ie the ;Pace belon: imous T- -q- mT(b'Iyo:i ; am ct!n-.a M 14 _ — L1.aci.Ly.r �s ST1 uqu- S7r,.1r [usmdiaw of Re erdl Town of Ca.N Stream IEQOESM STDPMRtrrnWRWWUT.11f. MWESTOR'SCONTACTWORMaTOSI E4Ir2 Fa :w` IiQOISI' Q1e111de • tel1Y nt fN rxaMnN h4 to f rH r 1'eF n. Y. AJmFfiO:LAt!!&Od1fAT104 T;E(.tP_)CtG I�- 'OUi1I TM RLQLIST is MARL KlSCA` TT0 FUMX RECORDS ACT. CNATFIX Ili OF TICC FLORIDA ST.A7C'TTS A`+D n ALSO REQCESFED r.%WR THE COSMM LAN RIGHT TO W%(M. THE COSDION LSN RIGHT OF ACCESS; .S0D ANl' STin*fOin WHT TO VOW (MUG, SITTIIOLT LtXMATIO`4 ,LS'T' ST %1170§n RIGTIT OF A(( tSS, -AS .StPIJC,SRLEL THIS REQITSI Is ALSO %LSOE PCTSC.LVF TO THE RIGHTS OF THE REQMTOBPROSIDEDL; THE FLORIDA CA \S7TTrmv. IIr. ro. a n. a MMZLLQLDiE(dl&XUJ fLUIV r rnit rr• CnDn IIL FOUL JTs' j: lcAa.t= kVnMjA92 ML g nLLQUUZp HATiM Alen"% lrorm ¢ rr"Itt"In 11 T Y PAfra Von n/uJ.C41Ta TTT(a t.rrrw.ni r, rwr rpm J,RQ�w ar tw QED ran�Qn a ar an r rnl arl nrrnmx rnrr*a +rr Rrnr�atrnmsr cr.7 ec r.uan err nnT ►LEASE 7101ME TILL Afr1Q -=UTt COm m Am TO RYFILL THO MLIC RIC omn 1TQITst T .Svv.tx(T. It N M nyrrri Am law F." ... ."re.. of s7 mm. ovrtre k M Am., C.! 4Ere a FI.nA. Samoa CLV W 11011 iDm.a.aw, a.&.v. PC a. a:n b".4 a.l. rJMma M flalnm P =131 f :l if t 7� if]I!1®L':N_DG I oil 1.]Edl11514'i211111l]IIIII blacl<baud Presents ihio t vinm,Q cerii icale to Freda Defosse Payroll Essentials June 73, 7013 1 POWERED BY Jm Oatr.6^3'aU MeredthC a Blackbaud Learn &x1 Dimclard EAsffiiorW Services �� I ii blacl<baud" To F,eda Def aaac From. Blackbaud. Inc Do"6Qa.2013 Ra CPECrmlda Blackbaud, Ericn au...,seed apevam ee Jm Nnienal Reparry of CPE Spenaen. Thn reyutry rtceyuzn prendm efcovnewvy pmfnnanvI educavoo forcecaununu that men aaba.Aly reCe/Nzed armduda. Youmry be ebtibl<m recerce CPE crcdiv fm NccnaPodS' mmpinintPayroB Euevtu6 The field of amly, dare. vumbn afUE credin and Blahbsud. Eec.'a Vanier idmtificatien amber are listed bebw You... vubmit du...fmmarion to yow mm board vfaccounmeq to receme CRE credits. State boards have fmal authority an the seeM aace of e,diiduvl comma for CPE Nedn. Clay. Name Pa3+o11 Euemuh Fuld of SNJy. Sp<culmed Rnowledte a,W Appl¢aeioN Date of Clan: lme?3. ?013 Lo A..: Deliren )fetLad: Group Intmet Hated NomLerofLRE Crn6b: 13 Nafmval Ratiary of CPE Spovavn IDq: 101131 In acfc�xvdavicew_its Jar arvvdnda ofthe Nvrieuel Re/nry of CPE Spenwn. CPE cedar h... bear ynmed bated en • 50 ben, hletedith C Johnna Circ IwofEducylilnal Service 1. Blackbaml. lucu repvnN mth the Na neral Avacuuov of$. Boards efAmwmmc, (NASBA3. as a spam. ofrmtureor, 1000 Darrel lslaod fh,ve, Chmlevay. SC 3949:-1541 p,e(nuenal edmabaewtLe Nmunal ReOao-ye(CPE Spentms Suu beads e(accotmtavry hnx Jte ENlawlmrtry on Ju 13?166'00 aczepuvice o[mdiv.An.l cemsn 6r CRE credit. Cwr ik......hnt re/istmed stonier, may be addressed to the Nitiaeal 81 P3216 2M mm Re4M'af C'PESp®m. 150Fe Avemu WoN Sute i00,W2J ille,N 57119411 Web um w..w code mo SPO, ORS CDC) D m EETM M rn nC) 771 cr CD I1 E tv {�\ \lt 2�10 } { \ � lCD !� i n o fib\ ti � O n � ACKNOWLEDGEMENT OF RECEIPT PALM BEACH COUNTY CODE OF ETHICS TRAINING FOR MUNICIPAL EMPLOYEESAND OFFICIALS* Check those items that apply I acknowledge that I have read a copy of the Palm Beach County Code of Ethics (printed or posted on the intranet/intemet) and completed additional training by: E✓J Watching the Code of Ethics Training Program on the Intranet/Internet. ❑ Watching the Code of Ethics Training Program on DVD. ❑ Attending a live presentation given on 20_. I understand that I am responsible for understanding and abiding by the Palm Beach County Code of Ethics as I conduct my assigned duties during my term of employment. I also understand that the information in this policy is subject to change. Policy changes will be communicated to me by my supervisor or through official notices. laton jn -�PLJ -P (Clearly Print the Name of Your Department) (Date) Employees: Submit signed form to your Department Head Department Heads: Submit signed forms to Records, Human Resources Advisory Board Members: Submit signed forms to appropriate municipal representative *This Form is for Municipal Employees and Elected/Appointed Officials 2633 Vista Parkway, West Palm Beach, FL 33411 561.233.0724 FAX: 561.233.0735 Hotline: 877.766.5920 E-mail: ethics@palmbeachcountyethics.com Website: www.paimbeachcountyethics.com PUBLIC EMPLOYEE'S OATH and OATH OF OFFICE I�2sru� �,55� a citizen of the State of Florida and of the United States of America, and being employed by or being an officer of the Town of Gulf Stream, Florida and a recipient of public funds as such employee or officer, do hereby solemny swear (or affirm) that I will support the Constitution of the United States and of the State of Florida. I do solemnly swear (or affirm) that I will support, protect, and defend the Constitution and Government of the United States and of the State of Florida against all enemies, domestic or foreign, and that I will bear true faith, loyalty, and allegiance to the same, and that I am entitled to hold office under the Constitution of the United States and the Constitution of the State of 'Florida, and h t I wihj� fa^io fully perform all the duties of the office of �M,\� V�SSj of the Town of Gulf Stream, Florida, on which I am about to enter, so help me God. Attested: n Dated this Z day of 4A Va'� (Witness) Town ofGulf Stream �.. Ir. • Participation Agreement www.benefitsworkshop.com/gulfstream • (888) 537-3539 • info@benefitsworkshop.com The Town of Gulf Stream sponsors a Health Reimbursement Account (HRA) Plan governed by the Internal Revenue Code. Employes eligible to participate in the Town's medical insurance plan are automatically participants in the HRA You are not required to enroll in the medical insurance plan to use the HRA. HRA participants will receive a debit card to use to pay eligible expenses under this plan. You must sign this form, agree to the following statement, and give this form to the Town Manager before you use the debit card. Name -(- Social Security Number Mailing Address (D City, State, ZIP Daytime Phone Number Order addltonal cards (ootionall. 3S2 ID # '1,-) - j' jC f,)& Is this//anew address? c3 Yes �o Email Address 4 PIPSSP_j-I �G (1.( 0_1 Q • CO 11L A BenefitsWorkshop Debit Card will be ordered in the employee's name only. A card can be ordered for your spouseldependents for a $5.00 handling fee. This fee will be deducted from your account balance. By providing the requested information, you are authorizing BenefitsWorkshop to deduct this fee from your account. Individual cards are not required to access the account. Name SS# ❑ spouse ❑ child Name SS# ❑ spouse ❑ child I hereby agree on behalf of myself, my spouse (if any) and any eligible dependents that: • My eligible dependents (if any) and I will only use the Town of Gulf Stream HRA debit card to pay for medical expenses as defined by the Plan for myself, my spouse (if any) or dependents (if any). • My dependents and I will not use the debit card or seek reimbursement from the HRA for any medical expense that has been reimbursed or that is reimbursible by any other plan. • I will obtain sufficient documentation (including invoices and/or receipts showing the date of service, the nature of the services and the amount paid) required by the IRS for any expense paid with the debit card. • I will submit such documentation to the Town's HRA administrator within ten (10) days of the date the debit card was used. • I understand that the ability to use the debit card may be suspended for failure to submit documentation in a timely mea rr, and I may be required to repay any undocumented or ineligible expenses. Participant Signature Date ' Entry Receipt Receipt of New Hire Entries Below Is a list of confirmed New Hires. New Hire Entries for: Town of Gulf Stream Date: 4/2/2013 11:22:50 AM Page 1 of 1 geho— Table of Contents _R-1 Forms L SSN Name Hire Date Birth Work Address City State Zip Country Date State •••,• Freda 03252013 03241959 FL 658 SW Boynton FL 33426 US DeFosse 1 Court Beach Print I Fleinilshed Please print a copy for your receipt. Sm,, Us I prm.ev Derv. Matralned by me Florida Department pr Revenue's Cbild Support Enticement Prpgram. P.O. Baa 6500 - Tallalussee. FL - 32314-6500 - 6eee/Jwww.mMmblf.mm1deN htti3s:Hnewhire.state.fl.us/fl-newhire/NewHireReceit)t.ast)x 4/2/2013 (DO NOT STAPLE) UnitedHealthcare Employee Enrollment Form To speed the enrollment process, please be thorough and fill out all sections that apply. Requested Effective Date of Coverage/Date of Change S" / / / /3 Group Name/Policy Number Date of Hire PositionRtle Hours Worked per Salary $ Required only if Life, STD, or LTD Plan based on salary Reason for Application 11New Groupp Plan eNew Hire ❑ Life Event/Date ❑ Annual ❑ Status Change Open ❑ Dependent Add/Delete Enrollment ❑ Change Name/Address ❑ Late ❑ Waiving Coverage Enrollee ❑ Termination Stat ❑ Other Language preference, 'd not English Employee Type (Check all that apply) WActive ❑ COBRA ❑ State Continuation Start dt _/ j End dt--/ —1 ❑ Hourly o Salary o Union ❑ Non -Union ❑ Retired ❑ Other If you are waiving all coverage, please complete sections A and F. Las a First Name MI Social Security NNuftr Home/Cell Phone %1810 )3G/ 15 } Work Phones S Address Apt # 'ty Stat Zip ode Language preference, 'd not English ^' L /the Date of Birt Sex Heigh j Weight Used tobacco in last Em I dress / / ❑ M F �# 12 months? ❑ Yes pQNo cOy2 Mar• al Status Physician* (First & Last Name)/ ID # Primary Care Dentist** (First & Last Name)/ ID # Ingle ❑ Married ❑ Divorced ❑ Widowed • 1 List All Enrolling (Attach sheet If necessary) Last Name First Name MI Sex Relationship*" Birthdate Height Weight Physician* (Name/[D#) Tobacco Social Security Number Primary Care Dentist** Name/ID# Used Spouse ci Yes — — F ❑ No M Dependent ❑ Yes — — F ❑ No M Dependent ❑ Yes — — F ❑ No M Dependent ❑ Yes — — F ❑ No M Dependent ❑ Yes F ii No *Important: For UnitedHealthcare products requiring you to choose a Primary Care Physician, you must use the UnitedHeafthcare directory of providers to choose a Primary Care Physician for yourself and each of your covered dependents. **Please see employer representative as some dental plans require a Primary Care Dentist (PCD) selection. ***For court ordered dependent, legal documentation must be attached. If dependent does not reside with eligible employee, please provide address an a separate sheet. Coverage Provided by "UnitedHealthcare and Affiliates": UnitedHealthcare Insurance Company or UnitedHealthcare of Florida, Inc. or Neighborhood Health Partnership, Inc. Dental coverage provided by UnitedHealthcare Insurance or UnitedHealthcare of Florida, Inc. or Neighborhood Health Partnership, Inc. Life, Short -Term Disability (STD), Long -Term Disability (LTD) Insurance coverage provided by UnitedHealthcare Insurance Company or Unimerica Insurance Company Vision coverage provided by UnitedHealthcare Insurance Company or Unimerica Insurance Company Sa.EE.10.FL 07/10 213-2184 1/11 Page t of 3 C Employee Name Please check the box for each coverage you or your dependents are enrolling in. If your employer offers a choice of plans, Indicate which plan you are selecting. Indicate the dollar amount selected for the Life and Accidental Death & Dismemberment (AD&D), Supplemental Life, Short -Term Disability IRTM and I nnn-Term nicnhilihi 11 Tm nlane nanafit nffarinne oro danandant ,mnn amnlnvar mlartinn .-•-„ -.._ --. .-.... Person Medical _._.._....i .-• .. r........ Dental ........ ..... ...y..... Vision Basic Life/AD&D I Supp Life/AD&D Employee Spouse ❑ Dependent ❑ ❑ ❑ 13 ❑ ❑$ $ ❑ $ ❑ $ ❑ $ ❑ $ 13 ❑ Person STD STD Buy Up LTD LTD Buy U Dependent Name: Employee ❑ $ ❑ $ ❑ $ ❑ $ Dependent Name: Life Insurance Beneficiary's Full Name and Address Relationship 'I This section must be completed to receive credit for prior medical coverage. Within the last 12 months, have you, your spouse, or your dependents had any other medical coverage? ❑ NO f KES (if yes, please complete this (section.) Prior medical carrier name ��� �� Effective dateLii1 End date) /�a Prior coverage type: dr>`mployee ❑ Spouse ❑ ChIld(ren) ❑ Family This section must be completed. (Attach sheet if On the day this coverage begins, will you, your spouse or any of your dependents be covered under any other medical health plan or policy, including another UnitedHealthcare plan or Medicare? ❑ YES (continue completing this section) p RO (skip the rest of this section) Name of other carrier Other Group Medical Coverage Information (only list those covered by other plan) Type (B/S/F)' Effective Date MM/DD/YY End Date MM/DD/YY Name and date of birth of policyholder for other coverage Employee: Spouse Name: Dependent Name: Dependent Name: Dependent Name: *B.Enter'B' when this dependent is covered under both you and your spouse's insurance plan (married) S. Enter'S' if you are the parent awarded custody of this dependent and no other individual is required to pay for this dependent's medical expenses. F. Enter 'P if this dependent is covered by another individual (not a member of your household) required to pay for this dependent's medical expenses. Medicare — Employee Information: If enrolled in Medicare, please attach a copy of your Medicare ID card. ❑ Enrolled in Part A: Effective Date ❑ Ineligible for Part A* ❑ Not Enrolled In Part A (chose not to enroll)*' Li Enrolled in Part B: Effective Date ❑ Ineligible for Part B* ❑ Not Enrolled in Part B (chose not to enroll)*' ❑ Enrolled in Part D: Effective Date ❑ Ineligible for Part D* ❑ Not Enrolled in Part D (chose not to enroll)** Reason for Medicare eligibility: ❑ Over 65 ❑ Kidney Disease ❑ Disabled ❑ Disabled but actively at work Are you receiving Social Security Disability Insurance (SSDI)? ❑ YES ❑ NO Start Date Medicare — Spouse/Dependent Name: ❑ Enrolled in Part A: Effective Date ❑ Ineligible for Part A' if Not Enrolled in Part A (chose not to enroll)** ❑ Enrolled in Part B: Effective Date ❑ Ineligible for Part B* ❑ Not Enrolled in Part B (chose not to enroll)** ❑ Enrolled in Part D: Effective Date ❑ Ineligible for Part D* ❑ Not Enrolled in Part D (chose not to enroll)** Reason for Medicare eligibility: ❑ Over 65 ❑ Kidney Disease ❑ Disabled ❑ Disabled but actively at work *Only check "Ineligible" if you have received documentation from your Social Security benefits that indicate that you are not eligible for Medicare. ** If you are eligible for Medicare on a primary basis (Medicare pays before benefits under the group policy), you should enroll in and maintain coverage under Medicare Part A, Part B, and/or Part D as applicable. Page 2 of 3 if waiving coverage I authorize UnftedHealthcare Insurance Company and its affiliates ('UnitedHealthcare and Affiliates') to obtain, use and disclose my medical, claim or benefit records, including any individually identifiable health information contained in these records. I understand these records may contain information created by other persons or entitles (including health care providers) as well as information regarding the use of drug, alcohol, mental health (other than psychotherapy notes), sexually transmitted disease and reproductive health services. I authorize any health care provider, pharmacy benefit manager, other insurer or reinsurer, hospital, clinic or other medical facility, health care clearinghouse, and any of their affiliates, representatives or business associates, to disclose my information to UnitedHealthcare and Affiliates. I understand the purpose of the disclosure and use of my information is to allow UnitedHealthcare and Affiliates to make decisions regarding underwriting and premium risk rating. I understand this authorization is voluntary and I may refuse to sign the authorization. My refusal may, however, affect my ability to enroll in the health plan or receive benefits, if permitted by law. I understand I may revoke this authorization at any time by notifying my UnitedHealthcare and Affiliates representative in writing, except to the extent that action has already been taken in reliance on this authorization. As required by HIPAA, UnitedHealthcare and Affiliates also request that I acknowledge the following, which I do: I understand that information I authorize a person or entity to obtain and use may be re -disclosed and no longer protected by federal privacy regulations. This authorization, unless revoked earlier, expires 30 months after the date it is signed. I understand that I am completing a joint life and health application and that each response must be complete and accurate. I (we) request the Indicated group medical coverage for myself and, if the plan provides, for my dependents. I authorize any required premium contributions to be deducted from earnings. I (we) have not given the agent or any other persons any health information not Included on the application. I (we) understand that UnitedHealthcare and Affiliates is not bound by any statements I (we) have made to any agent or to any other persons, if those statements are not written or printed on this application and any attachments. I have a continuing obligation to report changes in health status (e.g. received medical advice, diagnosis, care or treatment) after I sign the enrollment form and before receipt of my Identification card. UnitedHealthcare is only seeking to collect information about the current health status of those persons listed on the application. You should not include any genetic information. Please do not include any family medical history information or any Information related to genetic services or genetic diseases for which you believe you or your dependents may be at risk. Please maintain a copy of this authorization for your records. Any person who knowingly and with intent to Injure, defraud or deceive any insurer, files a statement of claim or an application containing any false, Incomplete or misleading information is guilty of a felony of the third degree. NOTE: Responding to this question is optional and is not required. Data collected in this section will be used only to help communicate with enrollees and inform them of specific programs to enhance their well-being. This information will not be used in the eligibility process. 1. Race, check all that apply: ❑ White ❑ Black, African-American ❑ American Indian/Alaska Native ❑ Asian ❑ Native Hawalian/Paciffc Islander ❑ Other Race, please specify 2. Are you of Hispanic or Latino origin? ❑ Yes ❑ No Page 3 of 3 Declining coverage due to existence of other coverage: I understand that by waiving coverage at this time, I will I decline all coverage for: Spouse's Employer's Plan ❑Individual Plan not be allowed to participate unless I qualify at a special o Myself 13 Covered by Medicare ❑ Medicaid enrollment period or as a late enrollee, if applicable, or at ❑S Pouse 13 COBRA from Prior Employer iiVA Eligibility 11 Tri -Care the next open enrollment period. i also understand that ❑ Dependent Children p ❑ Myself and all dependents ❑ Iwer have no other coverage at this time g Pre-existing Imitations may apply as explained in the Rights and Responsibilities brochure which I have 13 Other received with this form. if waiving coverage I authorize UnftedHealthcare Insurance Company and its affiliates ('UnitedHealthcare and Affiliates') to obtain, use and disclose my medical, claim or benefit records, including any individually identifiable health information contained in these records. I understand these records may contain information created by other persons or entitles (including health care providers) as well as information regarding the use of drug, alcohol, mental health (other than psychotherapy notes), sexually transmitted disease and reproductive health services. I authorize any health care provider, pharmacy benefit manager, other insurer or reinsurer, hospital, clinic or other medical facility, health care clearinghouse, and any of their affiliates, representatives or business associates, to disclose my information to UnitedHealthcare and Affiliates. I understand the purpose of the disclosure and use of my information is to allow UnitedHealthcare and Affiliates to make decisions regarding underwriting and premium risk rating. I understand this authorization is voluntary and I may refuse to sign the authorization. My refusal may, however, affect my ability to enroll in the health plan or receive benefits, if permitted by law. I understand I may revoke this authorization at any time by notifying my UnitedHealthcare and Affiliates representative in writing, except to the extent that action has already been taken in reliance on this authorization. As required by HIPAA, UnitedHealthcare and Affiliates also request that I acknowledge the following, which I do: I understand that information I authorize a person or entity to obtain and use may be re -disclosed and no longer protected by federal privacy regulations. This authorization, unless revoked earlier, expires 30 months after the date it is signed. I understand that I am completing a joint life and health application and that each response must be complete and accurate. I (we) request the Indicated group medical coverage for myself and, if the plan provides, for my dependents. I authorize any required premium contributions to be deducted from earnings. I (we) have not given the agent or any other persons any health information not Included on the application. I (we) understand that UnitedHealthcare and Affiliates is not bound by any statements I (we) have made to any agent or to any other persons, if those statements are not written or printed on this application and any attachments. I have a continuing obligation to report changes in health status (e.g. received medical advice, diagnosis, care or treatment) after I sign the enrollment form and before receipt of my Identification card. UnitedHealthcare is only seeking to collect information about the current health status of those persons listed on the application. You should not include any genetic information. Please do not include any family medical history information or any Information related to genetic services or genetic diseases for which you believe you or your dependents may be at risk. Please maintain a copy of this authorization for your records. Any person who knowingly and with intent to Injure, defraud or deceive any insurer, files a statement of claim or an application containing any false, Incomplete or misleading information is guilty of a felony of the third degree. NOTE: Responding to this question is optional and is not required. Data collected in this section will be used only to help communicate with enrollees and inform them of specific programs to enhance their well-being. This information will not be used in the eligibility process. 1. Race, check all that apply: ❑ White ❑ Black, African-American ❑ American Indian/Alaska Native ❑ Asian ❑ Native Hawalian/Paciffc Islander ❑ Other Race, please specify 2. Are you of Hispanic or Latino origin? ❑ Yes ❑ No Page 3 of 3 HUMANA. Specialty Benefits Benefits Enrollment Form TOWN OF GULF STREAM Please complete the following informab "' VI Vision Social Security No. Last Name first Middle Date -of Birth ► Employee + Family ❑ Home Address 3 Home Phone Gender City h 5 to �i ZIP C -de Bflness Phone Facility Number nc�tnx oyr'E)tguble Deprtdgnts Tt1re Ta6egat#ed First MI Last Facility Number Sex Birth Date Spouse: M ❑ F ❑ M❑ F❑ Child: M❑ F❑ Child: M❑ F❑ Child: M❑ F❑ Child: M❑ F❑ Child: M❑ F❑ Child: Effective Date: Plan Code: Group Number Your E-mail Address Agent Number VS6730 .4S}: (IIF('h 1 OIR (11010 . VI Vision Employee Only Employee One Employee + Child(ren) F1 Employee + Family ❑ 1 wish to enroll in the plan indicated above as offered through my employer. l understand that this is a minimum one(]) year contract 1 hereby authorize my employer to deduct all applicable contribution amounts from my salary orother compensation for the plan year, and for figure renewal period(s). I understand that such contribution tate is subject: to change on the anniversary date ofthe plan. I hereby represent that alllii�nffirmtaattion ffiuniisshedd by me hereon is true and complete to the best of my laawledge. th Signature: X . Air ,f 4l sC.-4Cn eL* Date: 4 I01,3 MetLife Metropolitan Life Insurance Company, New York, NY ENROLLMENT• CHANGE FORM GROUP CUSTOMER INFORMATION (To be Completed by the Recordkeeper) Name of Group Customer/Employer TOWN OF GULF STREAM Group Customer # 05721403 Division Class Dept Code Date of Hire M /DD c20 2')� Coverage Effecti a Dat (MWDDNYYY) ��0 t� Original COBRA Effective Date if applicable (MMIDDNYYY) COBRA Termination Date if applicable (MM/DDNYYY) YOUR ENROLLMENT INFORMATION (To be Completed by the Employee in blue or black ink) Name (First, M' dle, Last) F0 Social Security # �% ❑ Male �ingle f � . 55�— (—% — Female u Married Addr�$(Stree�ity, State, �p�de) r� �n `� � -1 Date of Birth MM/DD/YYYY) 5 � � a� 1 ® Employee Job Title:: n Hours W rked Per Week: ❑ Retiree � 1 Nv - % r\ S °1% New Enrollment ❑ Change in Enrollment ❑ COBRA Continuation If due to a Qualifying Event, enter date (MM/DD/YYYY) I have read my enrollment materials and I request coverage for the benefits for which I am or may become eligible. I understand the amounts of Insurance I request must comply with and are limited by the plan design described in my enrollment materials. Dental Insurance Select your level of coverage bM Employee Only ff Employee + Spouse ❑ Employee +Child(ren) ❑ Employee + Spouse + Child(ren) Dependent Information If you are applying for coverage for your Spouse and/or Child(ren), please provide the Information requested below: Name of your Spouse (First, Middle, Last) Date of Birth (MM/DD/YYYY) ❑ Male ❑ Female Name(s) of your Child(ren) (First, Middle, Last) Date of Birth (MM/DD/YYYY) ❑ Male ❑ Female ❑ Male ❑ Female ❑ Male ❑ Female ❑ Male ❑ Female ❑ Check here If you need more lines. Provide the additional information on a separate piece of paper and return it with your enrollment form. GEF02-1 ADM SUBMISSION INSTRUCTIONS After completion, make a copy for your records and return the original to MetLife Administration, P.O. Box 14593, Lexington, KY 40512-4593 Fax MetLife at 1-888-505-7446 Page 1 of 3 EF-XDP201S-NW (01/11) FRAUD WARNINGS..,,.:' Before signing this enrollment form, please read the warning for the state where you reside and for the state where the insurance policy under which you are applying for coverage was issued. Arkansas, District of Columbia, Louisiana, Massachusetts, New Mexico, Ohio, Rhode Island and West Virginia: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Colorado: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. Florida: A person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim or an application containing false, incomplete or misleading information is guilty of a felony of the third degree. Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files an application containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Maine, Tennessee, Virginia and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purposes of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. Maryland: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. New Jersey: Any person who files an application containing any false or misleading information is subject to criminal and civil penalties. New York: [only applies to Accident and Health Benefits (AD&D/Disability/Dental)]: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation. Oklahoma: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Oregon and Vermont: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law. Puerto Rico: Any person who knowingly and with the intention to defraud includes false information in an application for insurance or files, assists or abets in the filing of a fraudulent claim to obtain payment of a loss or other benefit, or files more than one claim for the same loss or damage, commits a felony and if found guilty shall be punished for each violation with a fine of no less than five thousand dollars ($5,000), not to exceed ten thousand dollars ($10,000); or imprisoned for a fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail term may be increased to a maximum of five (5) years; and if mitigating circumstances are present, the jail term may be reduced to a minimum of two (2) years. Pennsylvania and all other states: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. GEF09-1 Page 2 of 3 EF-XDP201S-NW (01/11) DECLARATIONS AND SIGNATURE By signing below, I acknowledge: 1. 1 have read this enrollment form and declare that all information I have given is true and complete to the best of my knowledge and belief. 2. 1 declare that I am actively at work on the date I am enrolling. 3. 1 understand that if I do not enroll for dental coverage during the initial enrollment period, a waiting period may be required before I can enroll for such coverage after the initial enrollment period has expired. 4. 1 authorize my employer to deduct the required contributions from my earnings for my coverage. This authorization applies to such coverage until I rescind it in writing. 5. 1 affirmatively decline coverage for any benefits for which I am eligible which I do not request on this enrollment form. 6. 1 have read the applicable Fraud Waming(s) provided in this enrollment form. GEF09-1 '� , a, ���1�� SSS L4 �25 Signature of Employee Print Name Date Sfgned (MMIDD/YYYY) Page 3 of 3 EF-XDP201S-NW (01/11) ��p D e a r b o r n N a t i o n a l � U n d e r w r i t t e n b y F o r t D e a r b o r n L i f e I n s u r a n c e E n r o l l m e n t a n d C h a n g e F o r m A d m i n i s t r a t i v e O f f i c e s : D o w n e r s G r o v e , I l l i n o i s I D a l l a s , T e x a s Q I M e w E n r o l l m e n t Q' C h a n g e Q' O p e n E n r o l l m e n t Q' C O B R A Q' R e t i r e e E m p l o y e r / E m p l o y e e S e c t i o n E n r o l l m e n t f o r m s m u s t b e s u b m i t t e d d i r e c t l y t o D e a ) 1 0 L o n g - T e r m D i s a b i l i t y ( L T D ) Q' D e p e n d e n t T e r m L i f e / A D & D % P r i m a ' 3 - C / ��r S u p p l e m e n t a l C o v e r a g e ( C h e c k a l l t h a t a p p l y ) ( A ) A d d , ( C ) C h a n g e S p o u s e i n c l u d e s D o m e s t i c P a r t n e r a n d P a r r y t o a C i v i l U n i o n a s d e f i n e d I n t h e C e r t i f i c a t e . ( D ) D e l e t e T o t a l A m o u n t o f C o v e r a g e D e s i r e d I t ( C ) h a n g e , l i s t P r i o r C o v e r a g e Q' T e r m L i f e / A D & D E m p l o y e e % Q' T e r m L i f e / A D & D S p o u s e Q' T e r m L i f e / A D & D C h i l d ( r e n ) V o l u n t a r y C o v e r a g e ( C h e c k a l l t h a t a p p l y ) ( A ) A d d , ( C ) C h a n g e S p o u s e I n c l u d e s D o m e s t i c P a r t n e r a n d P a r r y t o a C i v i l U n i o n a s d e f i n e d I n t h e C e r t i f i c a t e . ( D ) D e l e t e T o t a l A m o u n t o f C o v e r a g e D e s i r e d I f ( C ) h a n g e , l i s t P r i o r C o v e r a g e Q' T e r m L i f e E m p l o y e e Q' T e r m L i f e S p o u s e Q' T e r m L i f e C h i l d ( r e n ) Q' V o l u n t a r y A D & D Q' E m p l o y e e Q' F a m i l y Q' L o n g - T e r m D i s a b i l i t y ( L T D ) : I n c r e m e n t a l Q' L o n g - T e r m D i s a b i l i t y ( L T D ) : % o f E a r n i n g s Q' S h o r t - T e r m D i s a b i l i t y ( S T D ) : I n c r e m e n t a l Q' S h o r t - T e r m D i s a b i l i t y ( S T D ) : % o f E a r n i n g s S p o u s e N a m e - L a s t F i r s t M . 1 . ( I f A p p l i c a n t ) S e x Q' M Q' F S p o u s e D a t e o f B i r t h S p o u s e S o c i a l S e c u r i t y # H a s t h e e m p l o y e e ( i f a p p l y i n g ) u s e d a n y t o b a c c o p r o d u c t s i n t h e l a s t 2 y e a r s ? O f Y e s 0 , 4 0 H a s t h e s p o u s e ( i f a p p l y i n g ) u s e d a n y t o b a c c o p r o d u c t s i n t h e l a s t 2 y e a r s ? Q' Y e s Q' N o B E N E F I C I A R Y D E S I G N A T I O N : ( F o r E m p l o y e e O n l y : M u s t B e C o m p l e t e d i f y o u h a v e a p p l i e d f o r L i f e o r A D & D i n s u r a n c e . ) I f t w o o r m o r e p r i m a r y b e n e f i c i a r i e s a r e n a m e d , a n d y o u d o n o t l i s t b e n e f i t p e r c e n t a g e s , p r o c e e d s w i l l b e p a i d i n e q u a l s h a r e s t o t h e n a m e d p r i m a r y b e n e f i c i a r i e s w h o s u r v i v e y o u . I f n o p r i m a r y b e n e f i c i a r y s u r v i v e s y o u , p r o c e e d s w i l l b e p a i d t o t h e c o n t i n g e n t b e n e f i c i a r y ( i e s ) . I f y o u l i s t b e n e f i t p e r c e n t a g e s , t h e t o t a l m u s t e q u a l 1 0 0 % . ( E m p l o y e e i s t h e b e n e f i c i a r y o f p r o c e e d s f r o m s p o u s e o r c h i l d c o v e r a g e . ) F i r s t N a m e L a s t N a m e S o c i a l S e c u r i t v N o . I D a t e o f B i r t h I R e l a t i o n s h i o I P e r c e n t a g e P r i m a r 3 5 , ��j % P r i m a ' 3 - C / ��r l ) % ( ��( ��{ ��y % P r o d u c t s a n d s e r v i c e s m a r k e t e d u n d e r t h e D e a r b o r n N a t i o n a l � b r a n d a n d t h e s t a r l o g o a r e u n d e r w r i t t e n a n d / o r p r o v i d e d b y F o r t D e a r b o r n L i f e I n s u r a n c e C o m p a n y � ( D o w n e r s G r o v e , I L ) I n a l l s t a t e s ( e x c l u d i n g N e w Y o r k ) , t h e D i s t r i c t o f C o l u m b i a , t h e U n i t e d S t a t e s V i r g i n I s l a n d s , t h e B r i t i s h V i r g i n I s l a n d s , G u a m a n d P u e r t o R i c o . 9 - 5 5 2 - 4 1 1 F L P a g e 1 o f 2 R 7 . 2 6 / 1 1 I Z 5 2 2 2 F L Dearborn National® Enrollment and Change Form Underwritten by Fort Dearborn Life Insurance Company° Administrative Offices: Downers Grove, Illinois I Dallas, Texas BENEFIT SELECTION - DENTAL ENROLLMENT Date of Birth Relationship POLICYCHANGE CANCELCOVERAGE Spouse includes Domestic Partner and Party to SPOUSE ❑ M ❑ F a Civil Union as defined in the Certificate. ❑ M ❑ F (Choose One.) (Check Reason for Change) mployee ❑ Married ❑ Terminate Coverage ❑ Employee +Spouse ❑ Birth /Adoption 13 Employee + Child(ren) 13 Widowed Dater / ❑ Family ❑ Divorced ❑ Leave / Layoff ❑ Address Change ❑ Other Date: / / If above selection coversyour spouse, is your spouse If Yes, carrier's name: dental covered under any other plan? ❑ Yes ❑ No COBRA CONTINUATION PRIVILEGE Previously covered with group as: Start Dater / ❑ 1. Employee (termination, reduction in hours, other) Projected End Date: / / ❑ 2. Spouse (divorce from employee, death of employee) ❑ 3. Dependent (reached age limit, marded, no longer a Full Time Student, other) ❑ 4. Spouse & Dependents (divorce from employee, death of employee, other) For the purposes of this Notice, while prohibited by Federal law, Spouse does not include a same-sex Domestic Partner or Party to a Civil Union. Such benefits may be available under state law or provided by the policyholder. COVERED SPOUSE AND DEPENDENTS Dependent Child(ren) over the age limit, indicate if Full Time Student (FTS) or Handicapped (HDCP). Social Security First Name Last Name Number Date of Birth Relationship Adult Child FTS or Sex HDCP Name of Accredited School SPOUSE ❑ M ❑ F ❑ M ❑ F ❑ M ❑ F ❑ M ❑ F ❑ M ❑ F ❑ M ❑ F I hereby reeqquest to be insured and authorize deductions, if any, from my compensation for my share of the cost of the benefits to which I may be entitled under the group policy (ies) issued to the employer listed above. I understand that if I am not actively at work on the effective date of my coverage, my insurance will not begin until the day I return to work. I understand that if I do not remain activelyy, at work that my coverage may lapse or terminate. For those coverages I have declined, I understand that if I choose to enroll at a later date, my cost may be higher and a health questionnaire may be required. Any person who knowingly and with Intent to injure, defraud, or deceive any Insurer, files a statement of claim or an application containing any false, incomplete, or misleading information is�guilty of a felony of the third degree. r-oR IM USE ONLY EMPLOYEE SIGNATURE DATE l/D l Waiver of Coverage: I DO NOT WISH TO ENROLL at this time and understand that the opportunity to enroll at any future time will be subject to such arrangements as may be made with the company. EMPLOYEE SIGNATURE DATE Products and services marketed under the Dearborn Natlwal® brand and the star logo are underwritten and/or provided by Fart Dearborn Ufa Insurance Compan (Downers Grove, IL) In all states (excluding New York), the Dlstdct of Columbia, the United States Virgin Islands, the &lush Virgin Islands, Guam and Puerto Rico. 9-552-411 FL Page 2 of 2 R7.26111 I Z5222—FL Employment Eligibility Verification USCIS Form I-9 Department of Homeland Security OMB No. 1615-0047 U.S. Citizenship and Immigration Services Expires 03/31/2016 ►START HERE. 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 documentation presented has a future expiration date may also constitute illegal discrimination. Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment but not before accepting a job offer) Last Name Family Name) First Name (Given Name) Middle Initial )k Other Names Used (d any) Address (Street Number and Name) 1,5g� I r Apt. Number City or Town State R- Zip Code 133AaLp Date of Birt (mmmd/y)yy) �q U.S. Social Security Number E -mall Address ��5 � '11'com Telephone Number s� © 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): DffA citizen of the United States ❑ A noncitizen national of the United States (See instructions) ❑ A lawful permanent resident (Alien Registration Number/USCIS Number): ❑ An alien authorized to work until (expiration date, if applicable, mm/ddlyyyy) _ (See instructions) Some aliens may write "NIA" in this field. For aliens authorized to work, provide your Alien Registration NumbedUSCIS Number OR Form 1-94 Admission Number 1. Alien Registration Number/USCIS Number. OR 2. Form 1-94 Admission Number. If you obtained your admission number from CBP in connection with your arrival in the United States, include the following: Foreign Passport Number: Country of Issuance: Some aliens may write Signature of Employee: 3-D Barcode Do Not Write In This Space on the Foreign Pa!�Rort Number and Country of Issuance fields. (See instructions) Date (mm/dd/yy)y):. / /3 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. Signature of Preparer or Translator: I Date (mm/dd/yyyy): Name (Family Name) First Name (Given Name) (Street Number and Name) I City or Town I State It Employer Completes Next Page Form 1-9 03/08/13 N page 7 of 9 Section 2. Employer or Authorized Representative Review and (Employers ortheir authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR examine a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents" on the next page of this form. For each document you review, record the following Information: document title, issuing authority, document number, and expiration date, ff any.) Employee Last Name, First Name and Middle Initial from Section 1: I List OR List AND List Identity and Employment Authorization Identity Employment Authorization Document Title: D cumenl Title: Docugnt Title: (' 1 � Issuing Authority: Issuin uthoriry: Issuing Authors US Document Number: Do umenl Numbear Q Docu Expiration Date (if any)(mm/ddyyyy): Expiration Date (if a a any)(mm/ddyyyy): Expiration Date (if n)(mm/ddyyyy): Document Title: 3-13 Barcode Do Not Write in This Space Issuing Authority: Document Number: Expiration Date (if any)(mm/ddyyyy): Document Title: Issuing Authority: Document Number: Expiration Date (if any)(mm/ddyyyy): Certification I attest, under penalty of perjury, that (1) 1 have examined the document(s) presented by the above-named employee, (2) the above -listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States. / .Al n�1,n r me em�pruyee s nrst uay or emproymem immroaiyyyy/: V r ix, , r r. J r��= •••�••����,•� •�• a��••,r••�••�.r Authorized Representative First Nome (Given Name) City or Town thorized Representative 1� %sW nOm tJir. iizallo Name IQ State Zip Code Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.) A. New Name (d applicable) Last Name (Family Name) First Name (Given Name) Middle Initial B. Dale of Rehire (if applicable) (mm/ddyyyy): C. If employee's previous grant of employment authorization has expired, provide the Information for the document from List A or Usl C the employee presented that establishes current employment authorization In the space provided below. Document Title: Document Number: Expiration Date (if any)(mm/d&/Wy): I 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) I have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative: Date (mm/ddyyyy): Print Name of Employer or Authorized Representative: Form 1-9 03/08/13 N Page 8 of 9 From MTNkYTC W NDE I N2MwNz1I YnwwLj E_ Form Prxpom, Complete F= W-4 so that your emPbyer can withhold Ira correct federal Income fax Mom your pay. Conaidr compkfhg a new Form W -e saki )Y'em8f� and when your persona' or Nanctal sxuatlal Chengea am cornplete hen 2.3,4, aril 77 and �Igri the lam o vers(,,. A. Your mernPtion for 2013 anmkm February 17, 2010. See Pub. 505. Tax withholding and Estimated Tax Note, h KxrUW person can dale your m a dependent on his or her tax ,alum, you canna0OUr dein ceeds Roos end fndudes then SM of Unnamed roams 0cr exerrxxe. interest and dhalderdc). Basic Ineuuction . if you are not exempt• compute Me Personal Aeowainces Workshml below. The wworkalaeh on page 2 hnhe-a4$At Your whh adding alo vanes trued On nemZed deductions, cedes credits, adluabnente to krona, Or two -"mem Annuft le lobs eaueli". 03/26/2013 11:05 #966 P.001/OO1 https:Hdoe-04-18-docsvi ewer googieusercontemcomlviewer/securedo... Head of roumhold. GsnrAy, You ran claim head of homehold laky stabs on your tax return only M cCoeta e n of Int and PAY moue than 50% d the ePkg up a hare for yourself end your dependent(s) a Other gdWtykp frmNdsk. See Pub. 501, Exemptions, Slnroard 0edlcbm. and FAIng Idamuldon, for Infamalbn. I= cMdXL You cart take Proyded tax credits Into account In aevhg your a"owabla number of wKwIcklitV dependent weaxnpeanexsGanded s for chiltthe� tax credit may be claimed uskg the Pasond Anowncm Wel its' below. see Pub. 505 for information on OAveroV a"owwxe V� pilar cmdit into Walsld okg Nonwage Income. If you hero a I" amount of nonwage k,mnn, such as Mrmt or dividends. consider makig mbhated tax Peyneros ming Fomh 1040-p6, Esdmated I= for mdNHu". olhernks, you May owe add'd6YW tat b YOU have pension or annuity taw wmraoag an Farts W-4 a W41P. Two eamera ormultipie jobs. Ifyou have a workIng spouse a room then one lob, hgwe me tote' numbw of aaW671Cm }9U aro ehhltad to claim on all lobs using work0,,,e from only ore Form W4. Your Athhddng ueualy wla be Most scorsa it when a" aeowancm era cleirnea on the Fenn W-4 ed job ad j,e, are claimedd m tit others. See Pub. SM for ill.. Nouutalders aserc N you are a coresident ales, Notice IM for NanrS m ttal FroW4 rs5t �pldIng flus form. Alerts, before Check your whiftking. After Your Form W-4 tales effect. use Pub. 505 to am how the wront you re t�pr� 3 See pub 'm ptoo Your P•aleatIf your � atax exceed $130.000 (Si glal w 5190,000 (Menlaa). Future dermlopmaKi kdor nition abort any future developments affxYkg Form W-4 (such as W&klbn eracled after -8'Elm" It? WIN be posted at www.4saowW4. Persona IowencesWor haler(Keep for your records.) A Enter "1" for yourself if no one else can claim you as a dependant . r • You we single and have only one Job; or A B Enter"i" It f • You are married, have only one job, and your spouse does not work; or 111 B • Your wages from a second join a your spouse's wages (w the total of both) era $1,500 or less. C Ender "1"for your spouse. But you may choose to enter "-0-" if you are married and have either a working spouse or more than one job. (Entering "-0-' may help you avoid having too little tax withheld.) . . D Enter number of dependents (other than yours C poste or yourself] you will claim m your tax ,arum . D F E Enter "1" if you will file as head of household on your tax return (see conditions under Head of household above) E Enter "1" N you have at least $1,900 of child or dependent care expenses for which you Plan to claim a credit (Note. Do not include child support- F See Pub. 503, Child end Dependent care Expenses, for details.) G Child Tax Credit (Including additional child tax credit). See Pub. 972, Child Tax Credit for more information. • It your total income will be lass than $65,000 ($95,000 if marrieds enter "2" for each eligible cNW; then lase "1 • if you have three to six eligible children or leas "2" if you have seven or more eligible children. -If your total income MA be between $65,000 and $84,000 ($95,000 and $119,000 It married),enter III for each eligible child G H Add lines A through G and enter total here. (Nola. This may be different from the number or exemptions you clam, on yourtax retim.) ► H For acture • I1 you plan to harNzs or claim adjustments to Income and want to reduce your withholding, see fine Deductions and Adjustments Worksfleat on page 2. complete all a it You are single and have more, than one job Or are married and you and your spouse both wrork and the combined worksheets eami gs from all lobs exceed $40,000 ($10,000 If married), ata the Two-Eamrs/ eMula le Jobe Wwksheat on that eppfy, avoid having too Inde tax withheld. P page 2 to • If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W4 below. ------ _------- _____..__— Separate here and giro Fonn W-4 to your employer. Ke the top PPartfor your records. Form W-4 Employee's Withholding Allowance Certificate I OMB No. 1J545-0074 oeowwwtdeerresnryl ►Whether you" entitled to cWm a certain number of slimenom" exemption loom wltihooln h �/O ■Y exema tauter 8aads arebjeet to review ler the IRs. Your employer m y be required o sand copy of eua torn t theM.'s LAS 1 Yourfeexwmeondmlde"AVtial name V1.%r S-96 U Marded U Mamas, r—T7''�r; •r"„" ,..rw y cone-�-•--•--•--•--•-^,w. .w"aen, aaa as-sbpe. I C ` lJ a n yao t..e none dmn koro dal et,a.m on rouraoar s.euaty era. check hrw. You must cat 1•eg0.772.121$ fair. repieGnlalrt card. P. 5 TOtM number Of ellowences you are Claiming (from line H above or from the applicable worldil lest on page 2) S 5 Additional amount, if any, you want withhsd from each paycheck . 6 $ ^- 7 1 claim exemption from whhhalding for 2013, and I certify that I meet both of the following eancttlons for exemPtlon. • Last year I had a right to a refund of all federal income tax withheld because I had rho tax liability, and • This year 1 expect a rahrd of all federal hlcome tax withheld because I expect to have no tax Iiabilty. u......_Y.._.,_-- _ — _. . . . . . Is. dr 4 . J Data ► Act and Paperwork Reduction Act Notice, see page 2- Cal. No.102200 form w"4 r201s) LISTS OF ACCEPTABLE DOCUMENTS All documents must be UNEXPIRED Employees may present one selection from List A or a combination of one selection from List B and one selection from List C. LIST A Documents that Establish Both Identity and Employment Authorization 1. U.S. Passport or U.S. Passport Card 2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551) 3. Foreign passport that contains a temporary 1-551 stamp or temporary 1-551 printed notation on a machine- readable immigrant visa 4. Employment Authorization Document that contains a photograph (Forth 1-766) S. For a nonimmigrant alien authorized to work for a specific employer because of his or her status: a. Foreign passport; and b. Form 1-94 or Form 1-94A that has the following: (1) The same name as the passport, and (2) An endorsement of the alien's nonimmigrant status as long as that period of endorsement has ,4,, not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form. S. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form 1-94 or Forth 1-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI LIST B Documents that Establish Identity r; imp 1. Drivers license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address 2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address 3. School ID card with a photograph 4. Voters registration card 5. U.S. Military card or draft record 6. Military dependent's ID card 7. U.S. Coast Guard Merchant Mariner Card 8. Native American tribal document 9. Drivers license issued by a Canadian government authority For persons under age 18 who are unable to present a document listed above: 10. School record or report card 11. Clinic, doctor, or hospital record 12. Day-care or nursery school record LIST C Documents that Establish Employment Authorization 1. A Social Security Account Number card, unless the card includes one of the following restrictions: (1) NOT VALID FOR EMPLOYMENT (2) VALID FOR WORK ONLY WITH INS AUTHORIZATION (3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION by the Department of State (Form FS -545) 3. Certification of Report of Birth issued by the Department of State (Form DS -1350) 4. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal 5. Native American tribal document S. U.S. Citizen ID Card (Form 1-197) 7. Identification Card for Use of Resident Citizen in the United States (Form 1-179) 8. Employment authorization document issued by the Department of Homeland Security Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274). Refer to Section 2 of the instructions, titled "Employer or Authorized Representative Review and Verification," for more information about acceptable receipts. Form 1-9 03/08/13 N Page 9 of 9 TOWN OF GULF STREAM APPLICATION FOR EMPLOYMENT An Equal Opportunity Employer 100 Sea Road Gulf Stream, Florida 33483 (561) 276-5116 FOR OFFICE USE ONLY Application No. Date Posted (PLEASE PRINT PLAINLY IN BLUE OR BLACK INK) PERSONAL INFORMATION Date: Name (Last) (First) (Middle) V�e X05 5 -1-o-02s, C�nn Social Security Number Mailing Address City, State and ZIP Code X5,6 Sl.o I C-+ �1 K IF � 3-5Lf,� Telephone Number S&I g e 0 (-& Florida Driver's License Number (Only if applicable to position) CDL () Operator() Are you a citizen of the United States or a registered alien? ...................................................... Yes V No ( ) Have you ever been convicted of an offense against the law or forfeited collateral, or are you now under charges for any offense against the law? You may omit traffic violations for which you were fined $30 or less, and any offense committed prior to your 21st birthday that was finally adjudicated in a juvenile court or under a youthful offender law ................................................... Yes () No While in the military, were you ever convicted by a general court martial ............................................ Yes () No() If the answer is "Yes" to any of the above, give details below. For each offense, show the date, charge, place, court, and action taken. Attach extra sheets of paper if necessary. NOTE A conviction does not automatically mesa you will not be hired. Have you ever been employed by the Town of Gulf Stream before? If so, give dates of employment EDUCATION CIRCLE HIGHEST GRADE COMPLETED Grade School 1 2 3 4 5 6 7 8 High School 1 2 3 4 College 1 2 3 4 Graduate 1 2 3 4 Schools Name/Address Major Did you graduate? Degree i School GED lz, Graduate School Vocational School Other Training JOB INTEREST 1� Position Applied For. a �`I Date you can begin: Salary Desired: Will you accept: Temporary Work Yes O No (4-1pIrt-Time Work Yes O No (I MILITARY SERVICE RECORD Were you in the United Sates Armed Forces? Yes () No (L)/,'[ —Ycs,' what branch? Dates of Duty. to Grade at Discharge: 'Type of Discharge: List dud" in service, including special training received: Veterans Preference: YES NO SPECIAL SHILLS, APTITUDES and OTHER QUALIFICATIONS List details of all skills, aptitudes and other qualifi©dons that you feel are relevant to employment. Typing Spud words per minute Shorthand wpm Speed Writing wpm Office machin" you can operate efficiently. � ine r �' Zze, on 7(-'et � C ti\ C' cit � \ a`(( V'4'�(\\0. I,� r 1\ t Machinery or heavy equipment you can operate eRciently. Scholarships, fellowships, honors, elm, you have received: Special qualifications and skills (licenses, certificates, memberships in professional organizations or societies, etc): � n•�• �N Coynm REFERENCESg(Ezrludingrnier employers and relatives) Name and 1 z 3.CWA.�� �C,54\,A Address C+- 0 e- +f7s-A�oa���I Phone Numbers (Day and Evening) Sly t2g 4`-L-57� Additional copies of the inserted page for PRESENT AND PRIOR EMPLOYMENT may be made by the applicant or requested from Town Hall, as necessary. PRESENT AND PRIOR EMPLOYMENT Lis[ below all present and past employment beginning with your most recent. All spaces const be completed. A resume may be submitted, but it cannot substitute for completing the questions below. Do not answer a question below with "see resume." Name and Address of Company and Job Title: Qe Starting Last Type of Business: Hired ��rnl�l (� Y ? Salary Salary � X75 � � � ` \✓ SCS -3 MonthNear Describe the work you '_did: p 2CQ p �v\ad Name and Title of Supervisor May we contact your present/most recent a player at this time? Yes Left ``5__«Q�°� VD6t'3"._t'(�_Q '7 1'`Qe ISi'Q.1`2e�Q,�� (l�No () If "No," when? �-3 A::bi I �;> Co1�ca-k-aCS' S�r-dot } Sso r i.1�\�aC�1 Moath/Year l�p oc�6-art�S roar Y) r\(.6.0 s,,, )jDQxd%'l iSSf% 1 Telephone: a -SD CWo t,�F,etl n@CeS$o-a Reason for Leaving: 9�� tC�Cn 4� ,)ka`h\ C --DLJ QCLOU-!\ Y�'- n4 - Name and Address of Company and Type of Business: Hired Job Title: �M(!\ 5'� Starting Salary Last Salary b�S Month/Year 1-70 � did: Describe the work ypu d'd:� �y(� Name and Title Name E ck., i) 1 Left 5+'eaoxf e� e��5 1n 'g'4 �d1 q i) 4 t t� �t� 1 of Supervisor Month/Year n l n-K��n`ct n Telephone: ��(�15� Reason for Leaving: Name and Address of Company and Hired Job Title: Starting Last Type of Businesss� Cly OSsc9t�61Y1L7�� p Q3/�l %� /� (f� bV17r11S Salary Salary Month/Year �QI r Describe the /Jwork you di tbl) (1�S t��cle'�Ca�;S�7 y Name and Title qf&a Supervisor kt �l� n ji ll`C hcc51 >7 Left 'quP �� T^.sct�to r �2- Month/Ycar i1����rcnG 5�9 Telephone: f 0 X000 C �l IeM2r �cI Reason for Leaving: Additional copies of the inserted page for PRESENT AND PRIOR EMPLOYMENT may be made by the applicant or requested from Town Hall, as necessary. TOWN OF GULF STREAM ACKNOWLEDGMENT OF RECEIPT & UNDERSTANDING I hereby acknowledge that I have received and read a summary of the Towns Drug - Free Workplace policy, a summary of the drugs which may alter or affect a drug test and a list of local Employee Assistance Programs and drug and alcohol treatment programs. I have had an opportunity to have all aspects of this material fully explained. I understand that the full text of the Drug -Free Workplace policy is available upon request. I also understand that I must abide by the policy as a condition of employment, and any violation may result in disciplinary action, up to and including discharge. Further, I understand that during my employment I may be required to submit to testing for the presence of drugs or alcohol. I understand that submission to such testing is a condition of employment with the Town, and disciplinary action up to and including discharge may result if. 1) I refuse to consent to such testing, 2) I refuse to execute all forms of consent and release of liability as are usually and reasonably attendant to such examinations, 3) I refuse to authorize release of the test results to the Town, 4) the tests establish a violation of the Town's Drug -Free Workplace policy, 5) I otherwise violate the policy. If I am injured in the course and scope of my employment and test positive, I forfeit my eligibility for medical and indemnity benefits under the Workers' Compensation Act upon exhaustion of the remedies provided in Florida Stature 440.102(5). I ALSO UNDERSTAND THAT THE DRUG-FREE WORKPLACE POLICY AND RELATED DOCUMENTS ARE NOT INTENDED TO CONSTITUTE A CONTRACT BETWEEN THE TOWN AND ME. THE UNDERSIGNED FURTHER STATES THAT HE OR SHE HAS READ THE FOREGOING ACKNOWLEDGMENT AND KNOWS THE CONTENTS THEREOF AND SIGNS THE SAME OF HIS OR HER OWN FREE WILL. �s� �a_ ✓�2�5 5� Name (please print) Witness Signature Date 3-.27- L3 Date Appendix I GRIEVANCE PROCEDURE Section 1. Purpose The grievance procedures outlined here establish policies and procedures in employment and personnel management, and provide for an adequate and fair hearing of grievances pertaining to each individual's race, color, religion, sex, national origin, political affiliation, non - disqualifying disability or age, where the grievance is based upon denial of equal employment opportunity or discrimination. These procedures also relate to all other phases of employment for all employees of the Town of Gulf Stream. Section 2. Applicability/Coverage These grievance procedures apply to all departments and all persons employed by the Town. This policy does not guarantee any outcome other than a fair hearing of the grievance, and does not imply an employment contract or an obligation for any action on the part of the Town. Section 3. Policy Every employee shall have the right to present his or her problem or grievance in accordance with these procedures, with or without a representative of their own choosing, free from interference, coercion, restraint, discrimination, penalty, or reprisal. This includes any cause for dissatisfaction outside the employee's control or anything connected with his or her job that he or she thinks or feels is wrong. Every employee will be allowed such time off from his or her regular duties as may be necessary and reasonable as determined by the supervisor, department head and/or Town Manager, for processing a grievance under these procedures without loss of pay, vacation, or of other time credits. Section 4. Objectives The objectives of these procedures include the following: (a) To assure employees of a means to get their complaints considered rapidly, fairly, and without fear of reprisal. (b) To encourage employees to express themselves about how their conditions of work affect them as employees. Town of Gulf Stream, Florida, Personnel Policy Handbook I.1 EMPLOYEE ACKNOWLEDGEMENT FORM The Town of Gulf Stream Personnel Policy Handbook revised October 10, 2007 (the handbook), describes important information about the Town, and I understand that I should consult the Town Manager, Police Chief or Town Clerk regarding any questions not answered in the handbook. I have entered into my employment relationship with the Town voluntarily and acknowledge that there is no specified length of employment. Accordingly, either I or the Town can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law. Since the information, policies, and benefits described here are necessarily subject to change, I acknowledge that revisions to the handbook may occur, except to the Town's policy of employment -at -will. All such changes will be communicated through official notices, and I understand that revised information may supersede, modify, or eliminate existing policies. Only the Town Commission or the Town Manager has the ability to adopt policies that amend this handbook. Furthermore, I acknowledge that this handbook is neither a contract of employment nor a legal document. I have received the handbook, and I understand that it is my responsibility to read and comply with the policies contained in this handbook and any revisions made to it. EMPLOYEE'S SIGNATURE DATE EMPLOYEE'S NAME (TYPED OR PRINTED) Town of Gulf Stream, Florida, Personnel Policy Handbook 43