Application for Employment

Employee Direct Deposit Enrollment Form
To enroll in Full Service Direct Deposit, simply fill out this form. If depositing to a savings account, ask your bank to give you the Routing/Transit Number for your account. It isn’t always the same as the number on a savings deposit slip. This will help ensure that you are paid correctly. Below is a sample check MICR line, detailing where the information necessary to complete this form can be found.
Employee Direct Deposit Enrollment Form
IMPORTANT! Please read before completing and submitting.
AAA Apartment Staffing does not accept cash app banking information.
I hereby authorize AAA APARTMENT STAFFING to deposit any amounts owed me, as instructed by my employer, by initiating credit entries to my account at the financial institution (hereinafter “Bank”) indicated on this form. Further, I authorize Bank to accept and to credit any credit entries indicated by AAA APARTMENT STAFFING to my account. In the event that AAA APARTMENT STAFFING deposits funds erroneously into my account, I authorize AAA APARTMENT STAFFING to debit my account for an amount not to exceed the original amount of the erroneous credit. This authorization is to remain in full force and effect until AAA APARTMENT STAFFING and Bank have received written notice from me of its termination in such time and in such manner as to afford AAA APARTMENT STAFFING and Bank reasonable opportunity to act on it (7 business days minimum).
FIRST NAME (Must Match Bank Account)

February 5, 2023


• AAA Apartment Staffing will email the employee a password protected paystub (.pdf) on every Friday payday. Your emailed paystub password is the first four letters of your last name (lowercase) and the last four digits of your social security number. For example: George Washington SSN 123-45-6789 will have password: wash6789
• Mailed paychecks will delivered via the US Postal Service from Houston, TX and will be void and reissued after 30 days. To avoid delays please enroll in direct deposit today.

AAA Apartment Staffing
EQUAL EMPLOYMENT OPPORTUNITY – It is our policy to seek and employ the best qualified personnel in all of our facilities and to provide equal opportunity for the advancement of employees and to administer all of our personnel policies in a manner that will not discriminate against any person because of race, color, religion, age, sex, marital status, veteran status, national origin, ancestry, disability (physical or mental handicap), or any other legally protected status.
This complete application is only for job seekers who have already been approved for employment with AAA Apartment Staffing. If you have not yet been approved, please fill out the initial application.







This authorization entitles the bearer (or sender), or any representative thereof, to contact my present and past employer(s) for the purpose of confirming my length of employment, wages and other relevant employment data. AAA APARTMENT STAFFING 21366 Provincial Blvd. Katy, TX 77450 1-877-866-0830 Toll Free 1-877-464-1866 Toll Free Fax
I. I have been informed and do fully understand that my actions during employment shall be in accordance with the following policies/procedures and other company rules and regulations and any amendments thereto. The company shall have the right to amend, modify or revoke its rules at any time. I will familiarize myself promptly with such rules and regulations and will abide and be bound by the rules and regulations now and hereafter in effect. I understand that I am obligated to follow the policies/procedures listed below for AAA Apartment Staffing, as well as any policies/procedures for the company for which I am assigned.

II. I understand this acknowledgment is not intended to be and does not constitute a contractual arrangement or agreement of any kind between AAA Apartment Staffing and its employees. I understand my employment is "atwill" and not for a specified or definite term and that I may resign and may be discharged, at any time, for any reason, with or without good cause and with or without prior notice. This acknowledgment does not limit my right or the company's right to terminate employment at any time. No representative of the company, other than the Owners, have any authority to enter into an employment contract or change the nature of the employment relationship and even then, it must be in written format. The written format must contain signatures from both parties.

III. I understand that AAA Apartment Staffing is an Equal Opportunity Employer. The goal of the company policy is to provide equal employment opportunities according to any applicable federal, state or local ordinances without regard to race, color, religion, sex, national origin, age, disability, veteran status, or any other illegal basis. We will not unlawfully consider any of these factors.

IV. I understand the Company has an Open Door Policy. It is my responsibility to actively communicate to my immediate supervisor or manager when I have concerns or grievances that need to be addressed. I understand I should attempt to resolve my concerns, grievances, etc. with my immediate supervisor or manager first, but if there is no resolution or if there is a conflict with my immediate supervisor or manager, I have the option to contact any member of the management team regarding any concerns or grievances to be addressed. I understand that it is my responsibility to communicate all grievances/concerns/complaints to AAA Apartment Staffing and to the company for which I am assigned.

V. I understand the Company has a Harassment/Discrimination Policy. Harassment/discrimination including Sexual Harassment in the workplace is illegal and against company policy. Harassment is defined as any unwanted or unwelcome sexual or non-sexual behavior or advances, requests for sexual or non-sexual favors or other verbal or physical conduct of a sexual or non-sexual nature that (1) explicitly or implicitly are made a condition of employment, (2) are used as a basis for employment decisions, or (3) create a work environment that interferes with performance. Any violation of this policy will be considered a serious violation and will result in disciplinary action, up to and including discharge. If you witness or receive a harassment/discrimination complaint from a employee or non-employee, please report it to your supervisor immediately. I understand if I am being harassed, I can make it known to the harasser that the behavior is unwelcome. I understand that I am also responsible for reporting any harassment/discrimination claims to my immediate supervisor or manager, or any member of the management team of AAA Apartment Staffing as well as to the company for which I am assigned. Confidentiality will be maintained to the extent possible. Retaliations against employees who report harassment/discrimination claims and who assist in an investigation will not be tolerated.
• I certify that the answers given by me to the questions and statements on the employment applications and/or during the employment interview process are true and correct without any consequential omissions of any kind whatsoever. I understand that any misleading or incorrect statements may render the employment application and application process void and, if employed, would be cause for my termination. I further agree that AAA Apartment Staffing shall not be liable in any respect if my employment is terminated because of falsity of statements, answers or omissions made by me on the employment application or in the employment process.

• I authorize the companies, schools, persons or entities given during the employment process or on the employment application as references or past employers or affiliations to give any information regarding my employment, character qualifications, certifications and licenses and hereby release said companies, schools, persons or entities from all liability for any damage for providing this information. I understand that there may be state and federal requirements as well as insurance and employment requirements that will require periodic checks of all the above referenced sources. If employed, I further authorize periodic checks of all above referenced sources as may be deemed necessary by employer. A favorable result may be a condition of continued employment or commencement of any employment duties where elements are job-related.

• I understand that I may be required to have a medical examination and/or drug and alcohol test. A favorable result on the medical examination and/or drug and alcohol test would be a condition of commencement of any employment duties.

• I understand that my employment is not for a specified or definite term and that I may resign, or I may be discharged at any time, for any reason, with or without good cause and with or without prior notice. I further understand that this policy cannot be changed or amended except by written agreement signed by me and by a corporate officer.

• My employment shall be in accordance with the terms of the employment application, all safety and incident reporting rules, and all other Company rules and regulations.

• During the course of employment, there is a potential to have contact with many "customers". These "customers" may include, but are not limited to: visitors, vendors, consultants, contractors, service persons, customers, etc. This contact may include, but not be limited to: personal contact, written communication, telephone communications, e-mail communications or telecommunications of any type. The image of our organization is tied to the image of its employees, and to the extent that both of them intertwine, employees have a responsibility to represent the company's image accordingly. Employees should not have an expectation of privacy with respect to their telephone, e-mail or voicemail communications, telecommunications in general, the contents thereof, work areas or any general business work areas. Passwords are designed to minimize unauthorized access only. Workplace documents and communications are business records subject to possible review by the Company as well as outside parties. If you receive a customer complaint regarding harassment or discrimination, please report it to a member of management immediately. I have had the opportunity to review the basic policies and procedures and acknowledge these policies and procedures and agree to abide by them.
I understand that I am not required to work on any particular day and whether I report in to AAA APARTMENT STAFFING is always my choice. Whenever I wish to register my availability to work, I will call the office with my availability. I know that AAA APARTMENT STAFFING is not required to find work for me and is not required to contact me in any way in order to make work available to me. If I do not report to the dispatch call and sign in, AAA APARTMENT STAFFING may assume that I am not available for work on that day.

If I am asked to return to an assignment, I understand that it is my responsibility to notify AAA APARTMENT STAFFING of the duration of the assignment. If I do not report to the office, it will be assumed that I am not available for work.

I understand that any employment with AAA APARTMENT STAFFING is on a day-to-day basis. That is, at the end of the work day, I will be deemed to have quit unless and until I request and receive a work assignment at a later date. I understand I must call the local office to report available for further assignment within 24 hours of completing my assignment. I understand if I fail to do this I may not be eligible for unemployment benefits. I acknowledge that notices pertaining to my availability for employment are posted at the AAA APARTMENT STAFFING office.

I agree that any disputes arising out of my employment, including any claims of discrimination, harassment or wrongful termination that I believe I have against AAA APARTMENT STAFFING and all other employment related issues (excluding only claims arising under the National Labor Relations Act or otherwise within the jurisdiction of the National Labor Relations Board) will be resolved by arbitration as my sole remedy. The arbitration shall be conducted by the American Arbitration Association under its Commercial Arbitration Rules and the decision of the arbitrator shall be final and binding. I understand that AAA APARTMENT STAFFING also agrees to arbitrate in the same manner any claims which the company believes it has against me.
In consideration of my employment, I agree to conform to the rules and regulations of AAA APARTMENT STAFFING and I understand that my employment by AAA APARTMENT STAFFING may be terminated at any time by me or AAA APARTMENT STAFFING, with or without notice, for any reason. I understand that no General Manager, Assistant Manager or any other employee or representative of AAA APARTMENT STAFFING other than the President of AAA APARTMENT STAFFING has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to any of the foregoing.

CONFIDENTIALITY STATEMENT: Employees and former employees are prohibited from releasing to any other party any information whatsoever about AAA APARTMENT STAFFING which is of a confidential nature or which could be deemed to constitute a "trade secret." Employees or former employees are further prohibited from using, in any manner whatsoever, information which is confidential, proprietary, or privileged, whether for their personal benefit or gain, or for that of any other person. Any information which has not been disclosed publicly in writing should be treated as confidential and proprietary.

I understand the duties, including physical requirements of the position for which I am applying with AAA APARTMENT STAFFING and I certify that I am capable of performing the required tasks with or without reasonable accommodation. If any accommodation is necessary, I will describe the proposed accommodation on an attached sheet.
• AAA employees are not authorized to operate golf carts at the property.

• Maintenance Technicians are not authorized to solder inside or outside the units without written approval from AAA Apartment Staffing.

• Weapons in the Workplace: The possession of any weapon on your person, in your property, or in your vehicle is strictly prohibited while at any AAA Apartment Staffing client location. You do not have a right to carry a concealed weapon at any AAA Apartment Staffing client location, even if you are licensed to do so under state law.
I am either a temporary worker for AAA APARTMENT STAFFING (the "Company") or am applying for temporary work assignments with the Company.

I understand that the Company provides temporary workers for its customers to work at the customers' project site. In accepting any work assignment, I acknowledge that I am a temporary employee of the Company and am not an employee of the Company's customer.

If I am ever injured in the course of my work for the Company, I agree that I will look only to the Company's Workers' Compensation coverage and not to the Company's customer for any recovery. For myself, and on behalf of my heirs, executor, personal representative and assigns, I waive, release and forever discharge any claim that I may now have or that may later accrue against any customer of the Company which directly or indirectly arises out of any injuries which may occur to me while on a temporary work assignment for the Company.

In signing this Release, I understand that I am not waiving or releasing any claims which I may have against the Workers' Compensation coverage provided by the Company.
In consideration of my assignment to Client by Staffing Firm, I agree that I am solely an employee of Staffing Firm for benefits plan purposes and that I am eligible only for such benefits as Staffing Firm may offer to me as its employee. I further understand and agree that I am not eligible for or entitled to participate in or make any claim upon any benefit plan, policy, or practice offered by Client, its parents, affiliates, subsidiaries, or successors to any of their direct employees, regardless of the length of my assignment to Client by Staffing Firm and regardless of whether I am held to be a common-law employee of Client for any purpose; and therefore, with full knowledge and understanding, I hereby expressly waive any claim or right that I may have, now or in the future, to such benefits and agree not to make any claim for such benefits.
As a condition of my assignment by Staffing Firm to Client, I hereby agree as follows: I will not use, disclose, or in any way reveal or disseminate to unauthorized parties any information I gain through contact with materials or documents that are made available through my assignment at Client or which I learn about during such assignment. I will not disclose or in any way reveal or disseminate any information pertaining to Client or its operating methods and procedures that come to my attention as a result of this assignment. Under no circumstances will I remove physical or electronic documents or copies of documents from the premises of Client. I understand that I will be responsible for any direct or consequential damages resulting from any violation of this Agreement. The obligations of this Agreement will survive my employment by Staffing Firm.
I understand that as part of its regular employment policy, AAA APARTMENT STAFFING requires any employee who suffers a work-related injury or illness to be tested for the presence of drugs and/or alcohol. This testing is to be done at the location where initial treatment for the injury/illness is provided, and is to be conducted in accordance with acceptable medical procedures. I understand that if I refuse to submit to testing, it will be considered as refusal to comply with a reasonable request by my employer and will be cause for dismissal. I further agree to hold harmless AAA APARTMENT STAFFING, its principles, agents, and clients for any and all consequences arising from my testing positive for the use and/or influence of drugs or alcohol at the time of my injury or illness.
I fully understand that AAA APARTMENT STAFFING has strict policies that ban the use of unauthorized drugs. The ban includes the consumption of alcohol immediately prior to the beginning and during all scheduled work days. NO DRUGS NO ALCOHOL! I am aware that AAA APARTMENT STAFFING has a random drug testing policy. Drug testing may also be required by some clients and cooperation is required as a condition of employment. In the event of a work-related accident, an immediate drug/alcohol test is required.
I understand that AAA APARTMENT STAFFING has zero tolerance for sexual harassment and workplace violence. The penalty for either is immediate termination.
I understand and agree that AAA APARTMENT STAFFING may conduct a criminal background check through the court system. The signature below authorizes AAA APARTMENT STAFFING to conduct this inquiry.

Have you ever been charged with a Felony or Misdemeanor?

If yes, please explain:

Have you ever been convicted of a Felony or Misdemeanor?

If yes, please explain:

Do you consent to a two tiered background screening?
AAA Apartment Staffing has a two tiered screening process, you may receive a preliminary approval but a non-approval once both tiers have been fully completed.

Conviction will not necessarily preclude AAA Apartment Staffing from considering a person for the position applied for.

Falsifying any of the above information will result in a disqualification for the position applied for or immediate termination.
I understand and agree that for 90 days after the last day for which hours are scheduled and worked using the employment service provided by AAA APARTMENT STAFFING, I cannot accept permanent or temporary employment from any client or sister company to that client for whom I have worked. Clients also agree to this provision by signing the official time sheet each week (Please read and thoroughly understand the "Terms" on back of the "Official Weekly Time Sheet"). There are NO FEES for providing this employment service. Therefore, employees and clients utilizing AAA's services must abide by the work agreement specified on the back of the "Official Weekly Time Sheet."
I understand the importance of reporting injuries to AAA APARTMENT STAFFING as soon as they may occur. In the event of an on-the-job injury, I understand that it is my responsibility to report the injury to a representative of the client for whom I am working and then to immediately report the injury to the office of AAA APARTMENT STAFFING. I also understand that it is my responsibility to report unsafe working conditions and/or the lack of proper safety equipment.
Please Note: This is an online version of the Department of Homeland Security Form I-9. By signing this online version, you agree to use this form just as you would the PDF version. If you prefer, you may sign the PDF version of Form I-9 and fax it to (281) 584-9680 or email it to AAA Apartment Staffing.
START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ 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
Other Last Names Used (if any)
Address (Street Number and Name)
Apt. Number
City or Town
Zip code
Date of Birth (mm/dd/yyyy)
Last 4 of U.S. Social Security Number (XXXX)

Employee's E-mail Address
Employee's Telephone Number

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
2. A noncitizen national of the United States (See instructions)
3. A lawful permanent resident (Alien Registration Number/USCIS Number):
4. An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy): 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:

QR Code - Section 1 Do Not Write In This Space




Preparer and/or Translator Certification (check one):
I did not use a preparer or translator.
A preparer(s) and/or translator(s) assisted the employee in completing Section 1.
If you are using the assistance of a preparer and/or translator, please sign the PDF version of Form I-9 and fax it to (281) 584-9680 or email it to AAA Apartment Staffing.
Please Note: This is an online version of the Department of the Treasury Internal Revenue Service Form W-4. By signing this online version, you agree to use this form just as you would the PDF version. If you prefer, you may sign the PDF version of Form W-4 and fax it to (281) 584-9680 or email it to AAA Apartment Staffing. For a copy of the Multiple Jobs Worksheet and the Deductions Worksheet, reference page 3 of Form W-4. For Privacy Act and Paperwork Reduction Act Notice, also reference page 3.
Form W-4 (2023)
General Instructions
Section references are to the Internal Revenue Code.

Future Developments
For the latest information about developments related to Form W-4, such as legislation enacted after it was published, go to

Purpose of Form
Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. If too little is withheld, you will generally owe tax when you file your tax return and may owe a penalty. If too much is withheld, you will generally be due a refund. Complete a new Form W-4 when changes to your personal or financial situation would change the entries on the form. For more information on withholding and when you must furnish a new Form W-4, see Pub. 505, Tax Withholding and Estimated Tax.
Exemption from withholding.
You may claim exemption from withholding for 2023 if you meet both of the following conditions: you had no federal income tax liability in 2022 and you expect to have no federal income tax liability in 2023. You had no federal income tax liability in 2022 if (1) your total tax on line 24 on your 2022 Form 1040 or 1040-SR is zero (or less than the sum of lines 27, 28, and 29), or (2) you were not required to file a return because your income was below the filing threshold for your correct filing status. If you claim exemption, you will have no income tax withheld from your paycheck and may owe taxes and penalties when you file your 2023 tax return. To claim exemption from withholding, certify that you meet both of the conditions above by writing “Exempt” on Form W-4 in the space below Step 4(c). Then, complete Steps 1(a), 1(b), and 5. Do not complete any other steps. You will need to submit a new Form W-4 by February 15, 2024.
Your privacy.. If you have concerns with Step 2(c), you may choose Step 2(b); if you have concerns with Step 4(a), you may enter an additional amount you want withheld per pay period in Step 4(c).
Self-employment. Generally, you will owe both income and self-employment taxes on any self-employment income you receive separate from the wages you receive as an employee. If you want to pay income and self-employment taxes through withholding from your wages, you should enter the self-employment income on Step 4(a). Then compute your self-employment tax, divide that tax by the number of pay periods remaining in the year, and include that resulting amount per pay period on Step 4(c). You can also add half the annual amount of self-employment tax to Step 4(b) as a deduction. To calculate self-employment tax, you generally multiply the self-employment income by 14.13% (this rate is a quick way to figure your self employment tax and equals the sum of the 12.4% social security tax and the 2.9% Medicare tax multiplied by 0.9235). See Pub. 505 for more information, especially if the sum of self-employment income multiplied by 0.9235 and wages exceeds $160,200 for a given individual.
Nonresident alien. If you’re a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.
Specific Instructions
Step 1(c). Check your anticipated filing status. This will determine the standard deduction and tax rates used to compute your withholding.

Step 2. Use this step if you (1) have more than one job at the same time, or (2) are married filing jointly and you and your spouse both work.
If you (and your spouse) have a total of only two jobs, you may check the box in option (c). The box must also be checked on the Form W-4 for the other job. If the box is checked, the standard deduction and tax brackets will be cut in half for each job to calculate withholding. This option is roughly accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld, and this extra amount will be larger the greater the difference in pay is between the two jobs.

! CAUTION: Multiple jobs. Complete Steps 3 through 4(b) on only one Form W-4. Withholding will be most accurate if you do this on the Form W-4 for the highest paying job.

Step 3. This step provides instructions for determining the amount of the child tax credit and the credit for other dependents that you may be able to claim when you file your tax return. To qualify for the child tax credit, the child must be under age 17 as of December 31, must be your dependent who generally lives with you for more than half the year, and must have the required social security number. You may be able to claim a credit for other dependents for whom a child tax credit can’t be claimed, such as an older child or a qualifying relative. For additional eligibility requirements for these credits, see Pub. 501, Dependents, Standard Deduction, and Filing Information. You can also include other tax credits for which you are eligible in this step, such as the foreign tax credit and the education tax credits. To do so, add an estimate of the amount for the year to your credits for dependents and enter the total amount in Step 3. Including these credits will increase your paycheck and reduce the amount of any refund you may receive when you file your tax return.

Step 4 (optional).

Step 4(a). Enter in this step the total of your other estimated income for the year, if any. You shouldn’t include income from any jobs or self-employment. If you complete Step 4(a), you likely won’t have to make estimated tax payments for that income. If you prefer to pay estimated tax rather than having tax on other income withheld from your paycheck, see Form 1040-ES, Estimated Tax for Individuals.

Step 4(b). Enter in this step the amount from the Deductions Worksheet, line 5, if you expect to claim deductions other than the basic standard deduction on your 2023 tax return and want to reduce your withholding to account for these deductions. This includes both itemized deductions and other deductions such as for student loan interest and IRAs.

Step 4(c). Enter in this step any additional tax you want withheld from your pay each pay period, including any amounts from the Multiple Jobs Worksheet, line 4. Entering an amount here will reduce your paycheck and will either increase your refund or reduce any amount of tax that you owe.
Step 1. Enter Your Personal Information
Your first name and middle initial
Last name
City or town, state, and ZIP code
(b) Last Four of Your Social Security Number (XXX)

Single or Married filing separately
Married filing jointly or Qualifiying surviving spouse
Head of household (Check only if you're unmarried and pay more than half the costs of keeping 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, other details, 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) Reserved for future use.
(b) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below; 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 generally more accurate than (b) if pay at the lower paying job is more than half of the pay at the higher paying job. Otherwise, (b) is more accurate . . . . .

TIP: If you have self-employment income, see page 2.

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 and Other Credits
If your total 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 . . . . ? $
Add the amounts above for qualifying children and other dependents. You may add to this the amount of any other credits. Enter the total here . . . . . . . . . . . . . $
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 . . . . . . . . . . . . 4(a) $

(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 . . . . . . . . . . . . . . . . . . . . . 4(b) $

(c) Extra withholding. Enter any additional tax you want withheld each pay period . 4(c) $
Step 5: Employers Only (Completed by the Employer)
Employer’s name and address (Completed by Employer)
First date of employment (Completed by Employer)
Employer identification number (EIN) (Completed by Employer)

Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.
My signature indicates that I have read and agree to the above statements and have received copies of the New Health Insurance Marketplace Coverage Options form, the General Employee Safety Manual, and the ABA Minimum Essential Coverage documentation.
• Questions? Call (281) 584-0830 or toll free at 1-877-866-0830, Fax 1-877-464-1866.
February 5, 2023
Employee’s signature (This form is not valid unless you sign it.)

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Signature Certificate
Document name: Application for Employment
lock iconUnique Document ID: 1911d058dcdb216c60f912333dda59b26fb4a105
Timestamp Audit
February 8, 2022 3:13 am CSTApplication for Employment Uploaded by Anne O'Connell - IP