Pharmacist Employment Packet
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Pharmacist Employment Packet RPh on the Go USA, Inc. Proprietary Document: ©2015 All Rights Reserved
Dear Pharmacist:
Hello! Thank you for your interest in RPh on the Go. We are excited to share the opportunity for a
rewarding career with you.
We have a few requirements and forms for you to complete and return to us:
Application Packet — includes a general job description, required HIPAA training, application
for employment, skills checklist, a variety of authorization forms. Please complete the
application, skills checklist and sign the authorization forms and return them to us via email or
fax.
W-4 — please complete the bottom portion and return it with your application.
Direct Deposit Application — if you would like your paychecks deposited electronically,
please complete the application for direct deposit and include a copy of a voided check or
savings statement.
License and Resume — please include a copy of any active licenses and a copy of your
resume.
I-9 Form — please review the instructions for the Employment Eligibility Verification (I-9) form
carefully. The Federal Government requires that we receive your Employment Eligibility
Verification (I-9) on or before your third working day with us. If you are not in the Skokie,
Illinois area, please take this form and the required supporting documents to a trusted friend or
colleague (cannot be a member of your family). This person must review the documents,
complete Section 2 and the Certification sections. They are acting as our “authorized
representative”. Please FAX a copy to us immediately and send the original to us. If you are in
the Skokie, Illinois area, please call us to arrange a time to come to our office to complete this
process.
Also, some of our clients may require additional materials from you, such as a recent TB test, MMR,
proof of varicella immunization, proprietary training on their systems and processes, a physical exam
or other requirements. We will contact you as these items are needed and in many cases, we will help
make arrangements for completing the requirements.
Thank you for your interest in working with RPh on the Go. Please feel welcome to sign-in at
www.rphonthego.com and update your availability calendar and register your email address to
updates.
Thank you for joining our diverse and dynamic healthcare team. Please call me at 800-553-7359 with
any questions.
My best,
Steve Sidell
Director, Quality Assurance & Compliance
Pharmacist Employment Packet
Travel Pharmacist Job Description
POSITION SUMMARY
This is a per diem position for a registered pharmacist to provide professional services to a
variety of clients on behalf of RPh on the Go.
DUTIES AND RESPONSIBILITIES:
Maintains active state license.
Provides required health records, as determined by assignment.
Submits to requested drug screening(s).
Provides professional pharmacist cognitive services, which can include:
Filling prescriptions
Counseling patients
Checking for drug interactions
Other duties as defined on an assignment basis
Completes pre-assignment training requirements.
Each assignment that you accept will be performed by you to its completion.
Provide service to those assignments that you feel comfortable with and capable of
performing at a maximum professional level.
Comply with all applicable State laws and pharmacy regulations in the states where you are
working.
Submit a weekly timecard for each client.
Communicate with your Career Advisor and other RPh on the Go staff.
Maintain accurate contact information with RPh on the Go.
Immediately inform your Career Advisor or someone else on the RPh on the Go staff of
any adverse event, injury, or a concern about your working condition or assignment.
For each assignment:
Punctuality: Allow enough time to arrive and orient yourself to the facility before the
scheduled start-time.
Timecard: Submit a weekly timecard for each client.
Cooperation: Work in conjunction with the client staff at each assignment to provide the
highest quality healthcare.
Dress code: Present yourself in a professional manner, in accordance with client
requirements.
Customer service: Provide the highest level of customer service possible.
REQUIRED QUALIFICATIONS:
Active, valid pharmacist license in a U.S. state or territory
Must be eligible to work in the United States
LANGUAGE SKILLS:
Ability to read, speak, and write in English. Ability to read and interpret documents such as safety
rules, pharmaceutical documents and procedure manuals. Ability to write routine reports and
correspondence. Ability to effectively present information and respond to questions from patients,
coworkers and other healthcare professionals.
PHYSICAL DEMANDS:
Physical demands vary on a per-assignment basis. Reasonable accommodations may be made
to enable individuals with disabilities to perform the essential functions.
Signature: ________________________________________________ Date: ______________
Page 1
Pharmacist Employment Packet
Employment Application
RPh on the Go is an equal opportunity employer and does not discriminate on the basis of race,
religion, color, national origin, age, sex, gender, disability or any other characteristic protected by
law.
PERSONAL INFORMATION (please print)
First Name: ___________________________ MI: ________ Last: __________________________ Suffix: _____
How should your first name appear on your nametag? _______________________________________________
Address: ___________________________________________________________________________________
City: _________________________________________ State: _______ Zip Code: ________________________
Social Security #: _________________________ Driver’s License #: _________________State: _____________
List any other names (including maiden names) or social security numbers you have used: __________________
__________________________________________________________________________________________
Home Phone: _________________________________ Work Phone: __________________________________
Cell Phone: ___________________________________ Email: ________________________________________
Emergency contact: __________________________________________________________________________
Relationship: _______________________________ Telephone: _______________________________________
EDUCATIONAL AND PROFESSIONAL INFORMATION
Please include your resume, with your complete education and residency experience.
Pharmacy School Attended: ____________________________________________________________________
Degree(s): BS Pharmacy PharmD Other: ________________________________________________
National Practitioner Identifier (NPI) number: ______________________________________________________
An NPI number is not required by all of facilities, however RPh on the Go encourages our
employees to attain an NPI number. Please see https://nppes.cms.hhs.gov.
Please list all active and inactive pharmacist license(s). Please send a photocopy of all active
licenses.
Disciplinary Action
reprimand, probation, suspension, voluntary surrender,
Expiration revocation
State License Number
Date Past Disciplinary Current
Action Disciplinary Action
No Yes* No Yes*
No Yes* No Yes*
No Yes* No Yes*
No Yes* No Yes*
No Yes* No Yes*
No Yes* No Yes*
If you have other active or inactive licenses, please attach an additional sheet with details.
* Year of Disciplinary Action: _____________________ Explanation of past or current license
disciplinary actions
(attach a separate page if necessary): _________________________________________________________________
__________________________________________________________________________________________
Do you have liability/malpractice insurance? No Yes If yes:
Provider: _________________________ Policy Number: __________________ Expiration Date ____________
Page 2
Pharmacist Employment Packet
PHYSICAL RECORD
Do you need any special accommodations to perform the essential functions of your job? Yes No
If yes, please describe accommodations needed: ________________________________________________________
_______________________________________________________________________________________________
WORK EXPERIENCE
Please list your three most recent pharmacy-related positions. Please attach a copy of your current resume.
CURRENT EMPLOYER: __________________________________________________________________________
Please list any requests for contacting your current employer: ______________________________________________
Type of Business: Retail Long-term Care Hospital Out-Patient Hospital In-Patient Home Infusion Managed Care Other
Address: _______________________________________________________________________________________
City: ____________________________________ State: ________ Phone Number: ___________________________
Position: _______________________________________________ Salary: __________________________________
Dates Employed: from _________ to ___________ Reason for Leaving: ______________________________________
1) Supervisor or peer who can serve as a reference: ____________________________________________________
Title: ____________________________ Work Phone: ____________________ Cell phone: __________________
Email: ____________________________________ Dates worked together: ______________________________
2) Supervisor or peer who can serve as a reference: ____________________________________________________
Title: ____________________________ Work Phone: ____________________ Cell phone: __________________
Email: ____________________________________ Dates worked together: ______________________________
EMPLOYER: ____________________________________________________________________________________
Type of Business: Retail Long-term Care Hospital Out-Patient Hospital In-Patient Home Infusion Managed Care Other
Address: _______________________________________________________________________________________
City: ____________________________________ State: ________ Phone Number: ___________________________
Position: _______________________________________________ Salary: __________________________________
Dates Employed: from _________ to ___________ Reason for Leaving: ______________________________________
1) Supervisor or peer who can serve as a reference: ____________________________________________________
Title: ____________________________ Work Phone: ____________________ Cell phone: __________________
Email: ____________________________________ Dates worked together: ______________________________
2) Supervisor or peer who can serve as a reference: ____________________________________________________
Title: ____________________________ Work Phone: ____________________ Cell phone: __________________
Email: ____________________________________ Dates worked together: ______________________________
EMPLOYER: ____________________________________________________________________________________
Type of Business: Retail Long-term Care Hospital Out-Patient Hospital In-Patient Home Infusion Managed Care Other
Address: _______________________________________________________________________________________
City: ____________________________________ State: ________ Phone Number: ___________________________
Position: _______________________________________________ Salary: __________________________________
Dates Employed: from _________ to ___________ Reason for Leaving: ______________________________________
1) Supervisor or peer who can serve as a reference: ____________________________________________________
Title: ____________________________ Work Phone: ____________________ Cell phone: __________________
Email: ____________________________________ Dates worked together: ______________________________
2) Supervisor or peer who can serve as a reference: ____________________________________________________
Title: ____________________________ Work Phone: ____________________ Cell phone: __________________
Email: ____________________________________ Dates worked together: ______________________________
Page 3Pharmacist Employment Packet
Skills Checklist
Instructions: Please complete the following skills checklist by placing an "X" in the column which most accurately
indicates your level of experience with each listed item. The correlation between the numerical scale and level of
experience is as follows:
Print Name Here: __________________________________________________ Date: ___________________
1 - No Experience (Would require substantial training and instruction to perform independently)
2 - Minimal Experience (Would require supervision before performing independently)
3 - Moderate Experience (Would require a brief review before performing independently)
4 - Significant Experience (Can perform independently)
PHARMACY SOFTWARE
PRACTICE SETTINGS 1 2 3 4 SYSTEMS 1 2 3 4
Academia Cerner
Ambulatory Care CPR+
Clinic EPIC
Compounding Etreby
Consulting HBS
Correctional Facility (Jail) JASRx
Diabetes McKesson – 3PM
Drug Information McKesson – Pharmserv
Formulary Management Meditech
Geriatrics OPUS – ISM
Home Health OSCOR
Home Infusion PDX
Hospital – Inpatient PharmNet
Hospital – Outpatient Pharmtrak
Infectious Disease PROScript 2000
Long Term Care (LTC) QS1
Mail Order Rescot-Omni-DX
Military/Government/VA Rx-Link
Nuclear Speed Script
Oncology Superscript
Pain Management TechRx
Pediatrics WinPharm
Pharmaceutical Research Other (list):
Pharmacy Benefits
Management (PBM)
Poison Control AUTOMATION 1 2 3 4
Psychiatric Patient
Management Accumed/Baker Cells
Public Health BAXA-Rapid-Fill (ASF)
Retail – Chain BAXA-Repeater Pump
Retail – Independent Baxter
Sub-Acute Care Baxter-AUTOMIX Compounder
Baxter-MICROMIX
Veterinary Compounder
Other (list): Kirby Lester
McKesson-AcuDose-Rx
Page 4Pharmacist Employment Packet
McKesson-Baker Scale
McKesson-IntelliShelf-Rx
McKesson-MedCarousel
McKesson-ROBOT-Rx
CLINICAL AND JOB
RELATED EXPERIENCE 1 2 3 4 AUTOMATION (contd.) 1 2 3 4
Admixture McKesson-PACMED
Adolescent Care MTS-Automated Sealers
Aseptic Techniques MTS-Prepackaging
Blister Packs Parata-PACMED
Cart Check Parata-RDS
Cart Fill Parata-APM
Chemotherapy PharmASSIST-RDS ROBOTx
Computerized Physician
Order Entry PharmASSIST-SmartCabinet
Consulting PharmASSIST-SmartScale
Discharge Counseling Pyxis
DME Equipment Other (list):
Drug Information
PHARMACOKINETIC
Drug Information Rounds DOSING 1 2 3 4
Drug Rehabilitation
Programs Aminoglycosides
Emergency Room Anticoagulation
Enteral Nutrition Products Digoxin
Formulary Management Lithium
Geriatric Care Theophylline
Hazardous Drug Handling Vancomycin
Homeopathic Treatments Other (list):
Hyperalimentation
Calculation
DISEASE STATE
Immunizations MANAGEMENT 1 2 3 4
Immunoglobulin Therapy AIDS/HIV
Incontinence Supplies Anticoagulation
Infectious Disease Asthma
Infusion Pumps and
Systems Cardiovascular Disease
Intensive Care (ICU) Chemotherapy
IV Preparation Depression
Neonatal Intensive Care
(NICU) Diabetes
Oncology Dyslipidemia
Hormone Replacement
Ostomy Supplies Therapy
OTC Selection and
Recommendations Hypertension
P&T Committee Participant Osteoporosis
Pain Management Pain Management
PCA Pumps Smoking Cessation
Pediatric Care Transplant
Poison Control Other (list on next page):
Print Name Here: _______________________________________________ Date: __________________
Page 5Pharmacist Employment Packet
Psychiatric Care
Retail Compounding
Surgical Supplies
Tocolytic Therapy
TPN Preparation
Transplant Therapy
CLINICAL AND JOB
RELATED EXPERIENCE
(contd.) 1 2 3 4
Urological Supplies
Other (list):
Please check the boxes below for each age group for which you have expertise in providing age-appropriate care.
AGE SPECIFIC CRITERIA
A. Newborn/Neonate (birth – 30 days) D. Preschooler (3 – 5) G. Young Adults (18 – 39)
B. Infant (30 days – 1 year) E. School Age Children (5 – 12) H. Middle Age Adults (39 – 64)
C. Toddler (1 – 3) F. Adolescents (12 – 18) I. Older Adults (64+)
EXPERIENCE WITH AGE GROUPS A B C D E F G H I
Able to ensure safe and appropriate
medication dosages based upon the □ □ □ □ □ □ □ □ □
patient’s age
Able to adapt method and terminology
of patient instructions and counseling to
their age, comprehension, and maturity □ □ □ □ □ □ □ □ □
level
Can ensure a safe environment
reflecting specific needs of various age □ □ □ □ □ □ □ □ □
groups
Print Name Here: _______________________________________________ Date: __________________
Page 6Pharmacist Employment Packet
Terms and Agreements
By signing below, I agree to the following list of terms and agreements:
I certify that the facts contained in this application are true and complete to the best of my
knowledge and understand that, if hired, falsified statements on this application can be
grounds for dismissal.
HIPAA: I have reviewed the training material regarding the implementation and legal
consequences of HIPAA, Title II. I understand that I am responsible for reviewing each client’s
procedures on protecting the patient’s private health information.
PURPOSE: RPh on the Go was formed to provide licensed Registered Pharmacists in good
standing with a source of temporary employment. By signing this Agreement, you represent
that you are such a pharmacist and you agree to furnish pharmacy services performed by you
to our Clients as an employee of our company. We will offer these assignments to you so that
we mutually can fulfill our contractual obligations to these Clients.
COMPLIANCE: Each assignment that you accept will be performed by you to its completion.
You only need to service those assignments that you feel comfortable with and capable of
performing at a maximum professional level. In providing these services, you agree to comply
with all applicable State laws and pharmacy regulations in the states where you are working.
WAGE AND TIMECARDS: We will pay you a base rate, negotiated at the time of agreement
for each assignment. Additional compensation you might receive is reimbursement for
distances traveled from your home, room and board (if overnight accommodations are
necessary and approved), required “on call” time, appropriate pre-approved overtime work,
and special rates for certain specific jobs. These “extras” will be agreed upon by us before any
services are rendered by you. We will be fully responsible for these compensations once
confirmed. When you provide pharmacy services to our Clients, you will provide us with
signed time cards for the work once completed. You shall make no schedules or schedule
changes without written confirmation by RPh on the Go.
INSURANCE: If you drive a car to work, your responsibilities include maintaining current and
adequate auto insurance. We recommend that you maintain professional liability insurance.
Include proof of liability coverage with this application.
DISCIPLINARY ACTIONS: If any disciplinary action has occurred that affects your ability to
perform as a pharmacist in good standing, we must be immediately informed by telephone
and in writing. These changes may affect any future assignments we can offer you.
NON-COMPETE: During the term of an assignment and for twelve months following
termination of an assignment, you agree that you will provide pharmacy services to our
Clients only through our service. You agree that you will not provide pharmacy services to
such Clients directly or indirectly (as an employee, independent contractor, etc) for that
twelve-month period. Our contract with the Client prohibits the Client from hiring you without
paying a permanent placement fee to our company. Therefore, if prior to the expiration of
these twelve months a Client wants to hire you (as an employee or independent contractor,
etc), you agree to immediately notify us. In our sole judgment, we may waive the twelve-
month non-compete clauses provided we enter into a satisfactory compensation agreement
with the Client or you.
TERMS: This Agreement shall continue until (a) in our judgment, it is violated; or (b) thirty
days written notice is given by either party to terminate this Agreement. In either event, you
agree that the twelve month non-compete clause set forth above shall survive the termination
of this Agreement. This Agreement describes the entire obligation of each party to the other
and can only be changed in writing by both parties.
Pharmacist/Employee Signature: ______________________________________________________________
Print Name: _______________________________________________________ Date: _____________________
RPh on the Go USA, Inc. Signature: ______________________________________________________________
Print Name: _______________________________________________________ Date: _____________________
Page 7Pharmacist Employment Packet
RPh on the Go Mandatory Training
HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY ACT OF 1996
Please read the following information about the Health Insurance Portability and Accountability Act of 1996. By
signing the following page, you acknowledge that you are responsible for upholding the HIPAA guidelines and
reviewing each client’s procedures on protecting the patient’s private health information.
What is the purpose of HIPAA?
To provide health insurance portability from one employer to another
To improve healthcare efficiency by standardizing the exchange of medical information
To protect the patient’s privacy against the misuse or improper disclosure of health records
Who is affected by HIPAA?
All employee pharmacists, relief pharmacists, owner pharmacists, consultant pharmacists, health care system
pharmacists, interns, health care providers, health plan administrators, pharmacy technicians & support staff, who may
have access to a patient’s health information.
What is the definition of Personal Health Information (PHI)?
Any “individually identifiable” health information transmitted through conversation, computer, or paper. This includes
conversations with a patient, physician, nurse, clinic, health insurance representative, or pharmacy technician. Identifiable
information includes a patient’s name, address, social security number, e-mail address, photograph, date of birth, gender,
fax or phone number, driver’s license, or relative’s name. HIPAA does allow the use or disclosure of PHI to provide
treatment, to collect payment, and to conduct health care operations. Treatment is defined as dispensing, DUR
counseling, disease management, & refill reminders. Collecting payment is defined as verifying insurance coverage,
reconciliation of claims, and third party billing. Operations are defined as malpractice insurance and
hardware/software/database management. In addition, you may disclose PHI when required by law enforcement
investigations, court orders, subpoenas, government benefit programs, State Boards of Pharmacy, the FDA for adverse
events or product defects/recalls, or the Department of Health or CDC for disease or injury reporting.
How does HIPAA affect pharmacy operations?
When you counsel a patient (either in person or on the phone) regarding their medication, you should keep your voice low
and attempt to do so in a discreet area, so others cannot eavesdrop. PHI should not be within open view of other patients,
guests, customers, pharmaceutical sales reps, or delivery personnel. At the start of any assignment, it is imperative that
you review each client’s operations policies regarding documents and prescription vials containing PHI. Most pharmacies
staple the prescription receipt on the outside of the bag for identification purposes. To protect the patient’s privacy, the
pharmacy may use a smaller type font, so this information is not so visible. At the register checkout, the pharmacy may
place the receipt inside the bag or fold the receipt inside out and staple it to the outside of the bag. To discard paper
documents containing PHI, either tear or shred the document. Either return the old vial to the customer or destroy the
label before tossing any vial.
What is the Notice of Privacy Practices (NOPP)?
Effective with any prescriptions filled after 4-13-03, HIPAA requires that you post a copy of the Notice of Privacy Practices
in the pharmacy and provide a copy to each patient. This notice describes the patient’s privacy rights and explains how
the pharmacy intends to use and disclose PHI. You must attempt to obtain the patient’s written acknowledgement that
he/she has received the pharmacy’s privacy policy. If the patient refuses to sign, you are required to document your
efforts to obtain a signature and the reason why the patient did not comply. A parent or guardian may sign for a child’s
prescription. If requested by the patient, you are required to provide a written accounting of disclosures of PHI and the
pharmacy’s prescription records for up to 6 years prior to the date of request (but not prior to HIPAA’s effective date of 4-
13-03). Patients may request additional restrictions on the use or disclosure of their PHI and the type of communications
they prefer. Please familiarize yourself with and follow the client’s procedures.
Complaint Procedures
If a patient feels the pharmacy has breached their privacy by inappropriately sharing their PHI, communicate that the
pharmacy makes every attempt to respect their right to privacy. If the patient decides to pursue this further, provide the
contact information as described in Notice of Privacy Practices. In addition, a formal complaint may be filed with the
Secretary of Health & Human Services (listed on the NOPP).
How does HIPAA affect state laws?
HIPAA is a federal law that supercedes less stringent state laws, but not more stringent state laws. What are the legal
consequences of non-compliance with HIPAA?
Civil penalties up to $25,000 per rule violation.
Criminal penalties up to $50,000 and one year in prison for knowingly and improperly obtaining or disclosing
private health information.
Up to $250,000 fine and 10 years in prison for the sale, use, or transfer of private health information for
personal gain or malicious harm.
Sanctions apply to individual employees, not just the pharmacies.
Please keep this for your records.
Page 8Pharmacist Employment Packet
Background Search Data Form
The purpose of this form is to gather the information necessary to conduct your post-offer
background search. All employment is contingent upon favorable background search results. All
information will be kept confidential.
1. CANDIDATE INFORMATION
Candidate Name: _________________________________________________________________________________
Current Street Address: ___________________________________________________________________________
City, State, Zip Code: ______________________________________________________________________________
Social Security #: __________________________________
Driver’s License #: _________________________________________________ State Issued: __________________
2. THE FOLLOWING IS FOR IDENTIFICATION PURPOSES ONLY FOR THE BACKGROUND CHECK
Gender: (Circle one) Male Female Date of Birth: _______________________________
Additional Names Used in past 5 years: ______________________________________________________________
3. LIST ALL CITIES, COUNTIES, STATES AND COUNTRIES WHERE YOU HAVE RESIDED DURING THE PAST 5
YEARS OR NUMBER OF YEARS AS DETERMINED BY CLIENT:
City/Province County State Country* Approximate Dates
*If you have lived outside the United States you will be contacted for additional information.
4. Educational Data
Years Attended Did you Degree Type
School Print Name of School City, State, Zip
(2002-2004) Graduate? (BS,MBA)
College or
University
Other
College/Graduate
4. I certify that the above information is correct:
Signature: __________________________________
Print Name: _________________________________
Date: _______________________________________
BRANCH INFORMATION – FOR INTERNAL USE ONLY
Business Unit Name: ___________________ Branch Number: ____________ Title Applied For: _____________________________
Branch/Dept Contact: __________________________________ Start Date: ________________ Starting Salary:________________
Page 9Pharmacist Employment Packet
Mandatory Contact Notice
1. I understand and agree that, upon conclusion of each assignment, I must immediately
contact my RPh on the Go Health recruiter. I understand that such notification is for the
purpose of determining eligibility and availability of additional work assignments as well as
other administrative purposes. If the recruiter who initially placed me is not available, I can
speak with another recruiter, leave a detailed voicemail message in my recruiter’s mailbox, or
email the detailed message to my recruiter or to the email address below. I accept that:
a) My failure to contact RPh on the Go as indicated above within two business days* of
completion of assignment may be considered a voluntary resignation and/or termination
which may lead to the denial and/or interruption of unemployment benefits.
b) It is my responsibility to inquire about any available assignment with RPh on the Go upon
conclusion of my assignment. If I fail to inquire about another assignment prior to filing for
unemployment benefits, it may lead to an interruption and/or denial of unemployment
benefits.
c) If a suitable assignment is available with RPh on the Go upon conclusion of my
assignment and I refuse an offer of suitable work, it may lead to an interruption and/or
denial of unemployment benefits.
2. I also understand and agree that I am required to contact my RPh on the Go recruiter at the
telephone number or email address listed below:
a) When my address, email or phone number changes;
b) If I experience any type of harassment or unlawful discrimination;
c) If I am not being provided a meal or rest break to which I am entitled;
d) If I have a complaint or dispute about my wages earned;
e) If I am exposed to blood and/or bodily fluid or injured while on assignment.
If you have any questions, please contact your RPh on the Go recruiter.
RPh on the Go Contact Information:
General Email Address: callinavailable@rphonthego.com
Main Telephone: 847-588-7170
I certify that I have read, fully understand, and accept all terms of the foregoing agreement:
Employee Name: ______________________________________________________________
Employee Signature: ___________________________________________________________
Date: ________________________________________________________________________
*Exceptions to the two business day notification period are listed below:
Iowa – Associates must contact RPh on the Go within three working days of completion of the temporary
assignment.
Michigan – Associates must contact RPh on the Go within seven working days of completion of the temporary
assignment.
Page 10Pharmacist Employment Packet
Dispute Resolution and Arbitration
Agreement for Consultants/Associates
This Dispute Resolution and Arbitration Agreement for Consultants/Associates (“Dispute Resolution
Agreement”) is entered into as of this _____ day of ________________________ 20____, between RPh on the
Go, its successors and assigns and its officers, directors, employees, affiliates, subsidiaries and parent companies
(collectively referred to as the “Company”), and __________________________________________ (“Employee”).
Recitals
A. The Company desires to consider Employee for placement or the continuation of Employee on temporary
work assignments at Company’s client(s) (“Client(s)”);
B. Employee is desirous of such consideration or continued assignment; and
C. Employee and the Company desire to resolve any disputes concerning the terms, conditions or benefits of
Employee’s employment.
NOW THEREFORE, based on the above, and in consideration of the mutual covenants and conditions set
forth herein, the parties hereto agree as follows:
1. It is the Company’s goal that workplace disputes or claims be handled responsibly and on a prompt
basis. Employee and the Company are encouraged to take advantage of the procedures in the Company’s Open
Door Policy and Code of Business Conduct and solve problems and disputes informally, through dialog with
Employee’s supervisor, manager or Human Resources representative. Absent resolution through such process,
the Company and Employee agree that any and all disputes, claims or controversies arising out of or relating to
this Agreement, the employment relationship between the parties, or the termination of the employment
relationship, shall be resolved by binding arbitration in accordance with the Employment Arbitration Rules of the
American Arbitration Association then in effect. These Rules can be obtained from the Human Resources
Department or on line at www.adr.org. The agreement to arbitrate includes any claims that the Company may have
against Employee, or that Employee may have against the Company or against any of its officers, directors,
employees, agents, or parent, subsidiary, or affiliated entities, except as set forth below. The arbitration shall take
place in the county where Employee is or was last employed by the Company. The Company and Employee
agree that the aggrieved party must give written notice of any claim to the other party no later than the expiration of
the statute of limitations (deadline for filing) that the law sets forth for such claim. This Agreement shall be
enforceable under and subject to the Federal Arbitration Act, 9 U.S.C. Sec 1 et seq. and shall survive after the
employment relationship terminates. BY SIGNING THIS AGREEMENT, THE PARTIES HEREBY WAIVE THEIR
RIGHT TO HAVE ANY DISPUTE, CLAIM OR CONTROVERSY DECIDED BY A JUDGE OR JURY IN A COURT.
2. Except as it otherwise provides, this Dispute Resolution Agreement also applies, without limitation, to
disputes regarding the employment relationship, trade secrets, unfair competition, compensation, breaks and rest
periods, termination, or harassment and claims arising under the Uniform Trade Secrets Act, Civil Rights Act of
1964, Americans With Disabilities Act, Age Discrimination in Employment Act, Family Medical Leave Act, Fair
Labor Standards Act, Employee Retirement Income Security Act, Genetic Information Non-Discrimination Act, and
state statutes, if any, addressing the same or similar subject matters, and all other state statutory and common law
claims.
3. The arbitration requirement does not apply to (i) claims for workers compensation, state disability
insurance and unemployment insurance benefits; (ii) claims for employee benefits under any benefit plan
sponsored by the Company and covered by the Employee Retirement Income Security Act of 1974 or funded by
insurance; however, this Dispute Resolution Agreement does apply to claims for breach of fiduciary duty, for
penalties, or alleging any other violation of the Employment Retirement Income Security Act of 1974, as amended,
even if such claim is combined with a claim for benefits; and (iii) disputes that may not be subject to predispute
arbitration agreements as provided by the Dodd-Frank Wall Street Reform and Consumer Protection Act (Public
Law 111-203).
4. Regardless of any other terms of this Dispute Resolution Agreement, claims may be brought before an
administrative agency if applicable law permits access to such an agency notwithstanding the existence of an
agreement to arbitrate. Such administrative claims may include without limitation claims or charges brought before
the Equal Employment Opportunity Commission (www.eeoc.gov), the U.S. Department of Labor (www.dol.gov),
the National Labor Relations Board (www.nlrb.gov), or the Office of Federal Contract Compliance Programs
(www.dol.gov/esa/ofccp). Nothing in this Dispute Resolution Agreement shall be deemed to preclude or excuse a
Page 11Pharmacist Employment Packet
party from bringing an administrative claim before any agency in order to fulfill the party's obligation to exhaust
administrative remedies before making a claim in arbitration.
5. Although Employee will not be retaliated against, disciplined or threatened with discipline as a result of
his or her exercising his or her rights under Section 7 of the National Labor Relations Act by the filing of or
participation in a class, collective or representative action in any forum, the Company may lawfully seek
enforcement of this Dispute Resolution Agreement including the following class, collective and/or representative
action waivers under the Federal Arbitration Act and seek dismissal of such class, collective or
representative actions or claims.
6. Employee or the Company may apply to a court of competent jurisdiction for temporary or preliminary
injunctive relief in connection with an arbitrable controversy, but only upon the ground that the award to which
that party may be entitled may be rendered ineffectual without such provisional relief.
7. BY SIGNING THIS AGREEMENT, THE PARTIES AGREE THAT EACH MAY BRING CLAIMS
AGAINST THE OTHER ONLY IN THEIR INDIVIDUAL CAPACITY, AND NOT AS A PLAINTIFF OR CLASS
MEMBER IN ANY PURPORTED CLASS AND/OR COLLECTIVE PROCEEDING.
8. FURTHERMORE, BY SIGNING THIS AGREEMENT, THE PARTIES AGREE THAT EACH MAY BRING
CLAIMS AGAINST THE OTHER ONLY IN THEIR INDIVIDUAL CAPACITY AND NOT IN ANY
REPRESENATATIVE PROCEEDING UNDER ANY PRIVATE ATTORNEY GENERAL STATUTE (“PAGA
CLAIM”), UNLESS APPLICABLE LAW REQUIRES OTHERWISE. IF THE PRECEDING SENTENCE IS
DETERMINED TO BE UNENFORCEABLE, THEN THE PAGA CLAIM SHALL BE LITIGATED IN A CIVIL
COURT OF COMPETENT JURISDICTION AND ALL REMAINING CLAIMS WILL PROCEED IN ARBITRATION.
9. Within 30 days after signing this Agreement, Employee may submit a form stating that Employee wishes
to opt out and not be subject to the Dispute Resolution Agreement. Employee must submit a signed and dated
statement on a "Dispute Resolution and Arbitration Agreement for Consultants/Associates Opt Out Form" ("Form")
that can be obtained from the Company Human Resources Department at 847-588-7493 or
tina.musgrove@soliant.com. An Employee who opts out as provided in this paragraph will not be subject to any
adverse employment action as a consequence of that decision and may pursue available legal remedies without
regard to the Dispute Resolution Agreement. Should Employee not opt out of the Dispute Resolution Agreement in
a timely manner, Employee and the Company will be deemed to have mutually accepted the terms of the Dispute
Resolution Agreement.
10. It is understood and agreed by the parties that a Client and its affiliates are intended to be third party
beneficiaries to this Dispute Resolution Agreement. Although the Client and its affiliates are not the Employee’s
employer, any disputes that may be asserted against Client or its affiliates due to Employee’s temporary work
assignment at Client shall be resolved pursuant to this Dispute Resolution Agreement in the same manner as
claims made against the Company.
11. An Employee has the right to consult with counsel of the Employee's choice concerning this Dispute
Resolution Agreement. Employee has read this Dispute Resolution Agreement carefully, fully understands the
meaning of its terms and is signing it knowingly and voluntarily.
12. It is against Company policy for any Employee to be subject to retaliation if he or she exercises his or her
right to assert claims under this Dispute Resolution Agreement. If any Employee believes that he or she has been
retaliated against by anyone at the Company, the Employee should immediately report this to the Company
Human Resources Department.
13. The Company may change or modify the terms of the Dispute Resolution Agreement at any time with
reasonable prior notice to Employee. It is understood that future changes will supersede or eliminate, in whole or
in part, the terms of the Dispute Resolution Agreement. Current versions of the Dispute Resolution Agreement will
be posted by the Company on the Company’s internet site or such other location(s) designated by the Company.
14. If any provision(s) of this Dispute Resolution Agreement is declared overbroad, invalid or unenforceable
such provision(s) shall be severed from this Dispute Resolution Agreement and, the remaining provisions of this
Dispute Resolution Agreement shall remain in full force and effect and shall be construed in a fashion which gives
meaning to all of the other terms of this Dispute Resolution Agreement.
IN WITNESS WHEREOF, the parties have voluntarily and knowingly executed this Dispute Resolution Agreement
on the day and year first written above.
EMPLOYEE RPH ON THE GO
____________________________________________ ____________________________________________
Page 12DISCLOSURE AND AUTHORIZATION
[IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING AUTHORIZATION]
DISCLOSURE REGARDING BACKGROUND INVESTIGATION
Adecco Group NA (“the Company”) may obtain information about you for employment purposes from a third party consumer
reporting agency. Thus, you may be the subject of a “consumer report” and/or an “investigative consumer report” which may
include information about your character, general reputation, personal characteristics, and/or mode of living, and which can
involve personal interviews with sources such as your neighbors, friends, or associates. These reports may contain information
regarding your credit history, criminal history, social security verification, motor vehicle records (“driving records”), verification of
your education or employment history, or other background checks. Credit history will only be requested where such
information is related to the duties and responsibilities of the position for which you are applying. You have the right, upon
written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any
investigative consumer report and a copy of any report about you. Please be advised that the nature and scope of the most
common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your
education and/or employment history conducted by First Advantage P.O. Box 105292, Atlanta, GA 30348,1-800-845- 6004.
The scope of this notice and authorization is all-encompassing, however, allowing the Company to obtain from any outside
organization all manner of consumer reports and investigative consumer reports now and throughout the course of your
employment to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to
request disclosure of the nature and scope of any investigative consumer report.
New York and Maine applicants or employees only: You have the right to inspect and receive a copy of any
investigative consumer report requested by the Company by contacting the consumer reporting agency identified above
directly. You may also contact the Company to request the name, address and telephone number of the nearest unit of the
consumer reporting agency designated to handle inquiries, which the Company shall provide within 5 days.
ACKNOWLEDGMENT AND AUTHORIZATION
I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR
RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I
hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by the Company at any time
after receipt of this authorization and throughout my employment, if applicable. To this end, I hereby authorize, without
reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or
private), information service bureau, employer, or insurance company to furnish any and all background information requested
by First Advantage P.O. Box 105292 Atlanta, GA 30348, 1-800-845-6004, another outside organization acting on behalf of the
Company, and/or the Company itself. Their Privacy Policy can be reviewed at http://www.fadv.com/privacy-policy/. I agree
that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.
New York applicants or employees only: By signing below, you acknowledge receipt of Article 23-A of the New York
Correction Law.
Minnesota and Oklahoma applicants or employees only: Please check this box if you would like to receive a copy of a
consumer report at no charge if one is obtained by the Company. Ƒ
California applicants or employees only: Under section 1786.22 of the California Civil Code, you may view the file
maintained on you by the consumer reporting agency named above during normal business hours. You may also obtain a copy
of this file upon submitting proper identification and paying the costs of duplication services, by appearing at the Consumer
Reporting Agency identified above in person or by mail. You may also receive a summary of the file by telephone. The agency
is required to have personnel available to explain your file to you and the agency must explain to you any coded information
appearing in your file. If you appear in person, a person of your choice may accompany you, provided that this person furnishes
proper identification. Please check this box if you would like to receive a copy of an investigative consumer report or
consumer credit report at no charge if one is obtained by the Company whenever you have a right to receive such a copy
under California law. Ƒ
Washington State applicants or employees only: You also have the right to request from the consumer reporting agency
a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.
By signing below, I am also consenting to the sharing and transferring of information reported or learned about me to the Company’s
clients, affiliates and subsidiaries, now and at the time that I seek or maintain employment, assignment, or placement with or
through any of them.
Last Name: First Middle
Signature: Date:
Rev 7/13Criminal Conviction Questionnaire
It is essential that you answer the following questions about your background so that the Company can take into account
all factors. A prior criminal history will not necessarily disqualify you from employment with the Company; however, your
prior criminal history will be considered along with other factors such as the nature and severity of the offense, time that
has passed since the offense and/or the completion of the sentence and the nature of the position you are seeking. Your
answers to the following questions must be truthful, complete and accurate. If you do not answer the questions honestly
or you only provide part of the information, you will not be eligible for employment opportunities with the Company at the
present time or in the future. We recommend that you refer to your court records to complete the following questions. In
addition, you may want to contact your lawyer, the court, your probation/parole officer or seek other assistance in
completing this form.
(Print Name)
Name:_______________________________________________________ Last 4 SSN:___ ___ ___ ___
Last First Middle
1. HAVE YOU EVER BEEN CONVICTED OF, PLEAD GUILTY, NO CONTEST OR NOLO CONTENDERE TO A
FELONY OR MISDEMEANOR? *Please review all State Rules before answering*
Respond “No” if you have no convictions or if all convictions have been expunged, erased, sealed, annulled, dismissed
under a first offender’s law, pardoned or otherwise statutorily exonerated, eradicated or dismissed upon condition of
probation by the court, including sealed or expunged juvenile records of conviction or if the offense is a violation,
infraction or summary offense. Please note, convictions while you were a minor do not necessarily mean your conviction
is part of a sealed or expunged juvenile record or that you do not have to report it under applicable state law.
Yes (please complete questions 2-5, signature required) No (proceed to question 6, signature is required )
STATE RULES:
If you are currently a resident of or applying for work in California, answer NO if the conviction is: a) a
MISDEMEANOR conviction relating to Marijuana that is more than two (2) years prior to the date this questionnaire is
completed or b) relates to a referral to, and participation in, any pre-trial or post-trial diversion program.
If you are currently a resident of or applying for work in Connecticut please note that you are not required to
disclose the existence of any arrest, criminal charge or conviction, the records of which have been erased
pursuant to Connecticut General Statutes Sections 46b-146, 54-76o or 54-142a. Criminal records subject to erasure
pursuant to Connecticut General Statutes Sections 46b-146, 54-76o or 54-142a are records related to (a) determinations
of “delinquency” or that, as a child, you were a member of a family with service needs, (b) a ruling you are a “youthful
offender”, (c) a criminal charge that has been dismissed or nolled; (d) a finding you are not guilty for a criminal charge,
or (e) a conviction for which you have received an “absolute pardon”. Any person whose criminal records have been
erased pursuant to Connecticut General Statutes Sections 46b-146, 54-76o or 54-142a shall be deemed to never have
been arrested within the meaning of the general statutes with respect to the proceedings so erased and may so swear
under oath.
If you are currently a resident of the State of Massachusetts, answer NO if the conviction is a misdemeanor conviction
that: 1) is a sealed record, or 2) is a first conviction for drunkenness, simple assault, speeding, minor traffic violations,
affray or disturbances of the peace where the date of the conviction or the completion of any period of incarceration
resulting there from (whichever date is later) occurred five (5) or more years prior to the date of this questionnaire, unless
you were convicted of any other misdemeanor offense within the five years immediately preceding the date of this
questionnaire.
Adecco Group EOE M/F/D/V AOP32110 January 2014
Page 1 of 3Criminal Conviction Questionnaire
If you are currently a resident of or applying for work in Ohio, answer NO if the conviction is concerning minor
misdemeanor convictions for marijuana possession involving an amount less than 100 grams.
If you are currently a resident of or applying for work in Hawaii, please limit your response to 10 years unless
some period of incarceration resulting from a conviction took place within the last ten (10) years.
If you were convicted in New Jersey, when answering this question, please note that felonies refer to
crimes/indictments or criminal/indictable offenses and misdemeanors are generally referred to as disorderly persons
offenses
2. DETAILS OF CONVICTIONS:
If you answered “Yes”, please complete all fields below for each conviction. Please provide detailed information.
Responses such as “will discuss” are not acceptable. It is your responsibility to provide accurate and complete information.
Any uncertainty in answering the questions below should be resolved before submitting this questionnaire.
Conviction Felony or Date of Details of the offense. Sentence If you served Are you Provide date Age at the time
(Do not Misdemeanor Conviction If theft- related, specify or action time in jail, currently on Parole/Probation of conviction
abbreviate or (1.1) (Please the items involved, imposed what was your Parole/ was completed.
use penal note: this value of the items and by the date of Probation?
code date may the premises where court release?
numbers.) differ from offense took place
date of
arrest)
EXAMPLES:
March I stole an Iphone from 5 days in March 15, Yes, on Not complete.
Theft Misdemeanor 2013 a car that was parked jail. 1 2013 parole
in the parking lot year
where I worked. parole.
Iphone value was
$600.
3. EMPLOYMENT SINCE LAST CONVICTION:
Have you been employed for at least one year since your last conviction date or release date (whichever was later)?
Yes No
Adecco Group EOE M/F/D/V AOP32110 January 2014
Page 2 of 3Criminal Conviction Questionnaire
4. EVIDENCE OF REHABILITATION OR GOOD CONDUCT:
Do you have documentation of rehabilitation or good conduct that was obtained after your last conviction?
Yes No
If yes, you will be contacted by Adecco to provide a copy. Examples of such documentation may include:
x Transcripts, diplomas, certifications or letters from teachers evidencing training or education.
x References from an employer or job training program.
x Evidence of participation in counseling program or other workforce development or social service programs.
x Documentation of volunteer activities.
5. ADDITIONAL INFORMATION:
Do you have additional information that you would like Adecco to consider regarding your rehabilitation? Yes No
If yes, please add in the space provided below.
6. CERTIFICATION
I certify by signature below that the information provided on this form is true and complete. I understand that if I
fail to disclose a conviction or pending charge or provide false information, or if omissions or misrepresentations
are discovered, my application will be rejected and, if I am employed, my employment will be terminated. I
understand that I must inform the Company of any conviction and/or criminal charge that occurs while employed,
unless nondisclosure is protected by law. The transmission of this document by facsimile or electronic mail shall
constitute effective execution and delivery and may be used in lieu of the original for all purposes.
Signature: _______Date ______________________
Adecco Group EOE M/F/D/V AOP32110 January 2014
Page 3 of 3Form W-4 (2015) The exceptions do not apply to supplemental wages
greater than $1,000,000.
Nonwage income. If you have a large amount of
nonwage income, such as interest or dividends,
consider making estimated tax payments using Form
Basic instructions. If you are not exempt, complete
Purpose. Complete Form W-4 so that your employer the Personal Allowances Worksheet below. The 1040-ES, Estimated Tax for Individuals. Otherwise, you
can withhold the correct federal income tax from your worksheets on page 2 further adjust your may owe additional tax. If you have pension or annuity
pay. Consider completing a new Form W-4 each year withholding allowances based on itemized income, see Pub. 505 to find out if you should adjust
and when your personal or financial situation changes. deductions, certain credits, adjustments to income, your withholding on Form W-4 or W-4P.
Exemption from withholding. If you are exempt, or two-earners/multiple jobs situations. Two earners or multiple jobs. If you have a
complete only lines 1, 2, 3, 4, and 7 and sign the form Complete all worksheets that apply. However, you working spouse or more than one job, figure the
to validate it. Your exemption for 2015 expires may claim fewer (or zero) allowances. For regular total number of allowances you are entitled to claim
February 16, 2016. See Pub. 505, Tax Withholding wages, withholding must be based on allowances on all jobs using worksheets from only one Form
and Estimated Tax. you claimed and may not be a flat amount or W-4. Your withholding usually will be most accurate
percentage of wages. when all allowances are claimed on the Form W-4
Note. If another person can claim you as a dependent for the highest paying job and zero allowances are
on his or her tax return, you cannot claim exemption Head of household. Generally, you can claim head claimed on the others. See Pub. 505 for details.
from withholding if your income exceeds $1,050 and of household filing status on your tax return only if
includes more than $350 of unearned income (for you are unmarried and pay more than 50% of the Nonresident alien. If you are a nonresident alien,
example, interest and dividends). costs of keeping up a home for yourself and your see Notice 1392, Supplemental Form W-4
dependent(s) or other qualifying individuals. See Instructions for Nonresident Aliens, before
Exceptions. An employee may be able to claim completing this form.
exemption from withholding even if the employee is a Pub. 501, Exemptions, Standard Deduction, and
dependent, if the employee: Filing Information, for information. Check your withholding. After your Form W-4 takes
Tax credits. You can take projected tax credits into account effect, use Pub. 505 to see how the amount you are
• Is age 65 or older, having withheld compares to your projected total tax
in figuring your allowable number of withholding allowances.
Credits for child or dependent care expenses and the child for 2015. See Pub. 505, especially if your earnings
• Is blind, or exceed $130,000 (Single) or $180,000 (Married).
tax credit may be claimed using the Personal Allowances
• Will claim adjustments to income; tax credits; or Worksheet below. See Pub. 505 for information on Future developments. Information about any future
itemized deductions, on his or her tax return. converting your other credits into withholding allowances. developments affecting Form W-4 (such as legislation
enacted after we release it) will be posted at www.irs.gov/w4.
Personal Allowances Worksheet (Keep for your records.)
A Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . . A
B Enter “1” if: { • You are single and have only one job; or
• You are married, have only one job, and your spouse does not work; or
• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.
. . . B }
C Enter “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.) . . . . . . . . . . . . . . C
D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . . D
E Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . . E
F Enter “1” if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit . . . F
(Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)
G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.
• If your total income will be less than $65,000 ($100,000 if married), enter “2” for each eligible child; then less “1” if you
have two to four eligible children or less “2” if you have five or more eligible children.
• If your total income will be between $65,000 and $84,000 ($100,000 and $119,000 if married), enter “1” for each eligible child . . . G
H Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.) ▶ H
{
• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions
For accuracy, and Adjustments Worksheet on page 2.
complete all • If you are single and have more than one job or are married and you and your spouse both work and the combined
worksheets earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to
that apply. avoid having too little tax withheld.
• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.
Separate here and give Form W-4 to your employer. Keep the top part for your records.
Form W-4
Department of the Treasury
Employee's Withholding Allowance Certificate
▶ Whether you are entitled to claim a certain number of allowances or exemption from withholding is
OMB No. 1545-0074
2015
Internal Revenue Service subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
1 Your first name and middle initial Last name 2 Your social security number
Home address (number and street or rural route) 3 Single Married Married, but withhold at higher Single rate.
Note. If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.
City or town, state, and ZIP code 4 If your last name differs from that shown on your social security card,
check here. You must call 1-800-772-1213 for a replacement card. ▶
5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 5
6 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6 $
7 I claim exemption from withholding for 2015, and I certify that I meet both of the following conditions for exemption.
• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and
• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.
If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . ▶ 7
Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.
Employee’s signature
(This form is not valid unless you sign it.) ▶ Date ▶
8 Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.) 9 Office code (optional) 10 Employer identification number (EIN)
For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 10220Q Form W-4 (2015)You can also read
