cynthia coroa.pdf

TRUEBLUE company

ACKNOWLEDGEMENT OF RECEIPT

I herby certify that, in accord with my employer's policy and any applicable federal safety regulations, I have been provided and have received a handbook on alcohol misuse and substance abuse in the workplace and FAA approved Antidrug Plan; and received training on drug use and abuse consequences and effects.

I have read through and understand what m y options are should I test positive for either alcohol misuse or prohibited drug use.

M /MU As ' PAOLA COROA 315- zs- 43(06:

NAME (PLEASE PRINT) SOCIAL SECURITY NUMBER

po (4, SIGN DATE

03 -P .31 - 1S

A. Employer Name, Address, I.D. No.

PLANE LLC NBINGTOM RD.

B. MRO Name, Address, Phone No. and Fax No.

MD

Collector Fax No.

Signature of Donor

p •fl x ; A c ( 1: " /.36 Itc Date (MolDaylYr)

M 'I Fl IA c r/) 61 ("r•7l:'( v.? (PRINT) Donor's Name (First, MI, Last)

japporp Laboratory CorpOration of America Holdings

0 69 First Ave., Raritan, NJ 08869 FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM ❑ 1904 T.W. Alexander Dr., Research Triangle Park, NC 27709

':• • :' n t. v . d . 1. ':.L, a A; ❑ 1120 Main Street, Southaven, MS 38671 :. NY,) ❑ 7207 North Gessner, Houston, TX 77040 C-,,WNiF,T. S-,.,0-'3"n-79

SPECIMEN ID NO. 079071_4 2,71 STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE

ACCESSION NO.

D. Specify TeSting Authority: ❑ HHS ❑ NRC DOT — Specify DOT Agency: ❑ FMCSA 1,21 FAA ❑ FRA ❑ FTA ❑ PHMSA ❑ USCG

E. Reason for Test: 6 ,Pre-employment El Random E] Reasonable Suspicion/Cause ❑ Post Accident El Return to Duty ❑ Follow-up ❑ Other (specify)

F. Drug Tests to be Performed: THC, COC, PCP, OPI, AMP ❑ THC & COC Only ❑ Other (specify) G. Collection . Site Address::,,

It•

STEP 2: COMPLETED BY COLLE „GCT R (make remarks when appropriate) Colleptor reads specimen temperature within 4 minutes. Temperature between 90° and 100° F? YYes ❑ No, Enter Remark Collection: )'Split ❑ Single ❑ None Provided, Enter Remark I ❑ Observed, Enter Remark

REMARKS

STEP 3: Collector affixes bottle seal(s) to bottle(s). Collector dates seal(s). Donor initials seal(s). Donor completes STEP 5 on Copy 2 (MRO Copy) STEP 4: CHAIN OF CUSTODY - INITIATED BY COLLECTOR AND COMPLETED BY TEST FACILITY I certify that the specimen given to me by the donor identified in the certification section on Copy 2 of this form was collected, labeled, seal d argl released to the Delive'ry Service noted in accordance with applicable Federal requirements.

/ f 1 f ',i

X //' /AAA. k6, ,A . 't. , i./ :..4 ..- ' ,, Signature of Collector

00 ' A 10 1 A -' (PRINT) Collettor's Name (First, MI, Last)

SPECIMEN BOTTLE(S) RELEASED TO:

C —

Name of Delivery Service

jj Aryl

!)) , (PM

Date(MolDay/Yr) Time of Collection —

STEP 5: COMPLETED BY DONOR I certify that I provided my urine specimen to the collector; that I have not adulterated it in any manner; each specimen bottle used was sealed with a tamper-evident seal in my presence; and that the information provided on this form and on the label affixed to each specimen bottle is correct.

Daytime Phone No. ( '''' 1 -7 ) -16 0 - 0 to .3 Evening Phone No. ( ) Date of Birth 0 "1.' / ( :•3 / IV ,?$' (MolDaylYr)

After the Medical Review Officer receives the test results for the specimen identified by this form, he/she may contact you to ask about prescriptions and over-the-counter medications you may have taken. Therefore, you may want to make a list of those medications for your own records. THIS LIST IS NOT NECESSARY. If you choose to make a list, do so either on a separate piece of paper or on the back of your copy (Copy 5). — DO NOT PROVIDE THIS INFORMATION ON THE BACK OF ANY OTHER COPY OF THE FORM. TAKE COPY 5 WITH YOU.

STEP 6: COMPLETED BY MEDICAL REVIEW OFFICER - PRIMARY SPECIMEN In accordance with applicable Federal requirements, my verification is:

❑ NEGATIVE ❑ POSITIVE for 111 DILUTE

❑ REFUSAL TO TEST because — check reason(s) below:

IIITEST CANCELLED -

- ❑ ADULTERATED (adulterant/reason): ❑ SUBSTITUTED

❑ OTHER:

REMARKS'

X Signature of Medical Review Officer

(PRINT) Medical Review Officer's Name (First, MI, Last)

Date (MolDaylYr)

STEP 7: COMPLETED BY MEDICAL REVIEW OFFICER - SPLIT SPECIMEN In accordance with applicable Federal requirements, my verification for the split specimen (if tested) is: ❑ RECONFIRMED for: ['TEST CANCELLED

❑ FAILED TO RECONFIRM for

REMARKS•

X Signature of Medical Review Officer (PRINT) Medical Review Officer's Name (First, MI, Last) Date (MolDay/Yr)

COPY 5 - DONOR COPY

Instructions for Completing the Federal Drug Testing Custody and. Control Form When making entries use black or blue ink pen and press firmly

Collector ensures that the name and address of the HHS-certified Instrumented Initial Test Facility (IITF) or HHS-certified laboratory are on the top of the CCF and that the Specimen I.D. number on the top of the CCF matches the Specimen I.D. number on the labels/seals.

STEP 1:

• Collector ensures that the required information is in STEP 1. Collector enters a remark in STEP 2 if Donor refuses to provide his/ her SSN or Employee I.D. number.

• Collector gives collection container to Donor and instructs Donor to provide a specimen. Collector notes any unusual behavior or appearance of Donor in the remarks line in STEP 2. If Donor conduct at any time during the collection process clearly indicates an attempt to tamper with the specimen, Collector notes the conduct in the remarks line in STEP 2 and takes action as required.

_STEP 2:

as required.

• Collector inspects the specimen and notes any unusual findings in the remarks line in STEP 2 and takes action as required. Any specimen with unusual physical charactenstics . (eg. unusual color, presence of foreign objects or material, unusual odor) cannot be sent to an IITF and must be sent to an HHS-certified laboratory for testing as required.

• Collector determines the volume of. specimen in the collection container. If the volume is acceptable, Collector proceeds with the collection. If the volume is less than required by the Federal Agency, Collector takes action as required, and enters remarks in STEP 2. If no specimen is collected by the end of the collection process, Collector checks the None Provided box, enters a remark in STEP 2, discards Copy 1 and distributes remaining copies as required.

• Collector checks the Split or Single specimen collection box. If the collection is observed, Collector checks the Observed box and enters a remark in STEP,

STEP 3:

• Donor watches Collector pour the specimen from the collection container into the specimen bottle(s), place the cap(s) on the specimen bottle(s), and affix the labeffsyseaffs) on the specimen bottle(s).

Collector dates the specimen bottle label(s)/seal(s) after placement on the specimen bottle(s).

■ Donor initials the specimen bottle label(s)/seal(s) after placement on the specimen bottle(s).

• Collector turns to Copy 2 (Medical Review Officer Copy) and instructs Donor to read and complete the certification statement in STEP 5 (signature, printed name, date, phone numbers, and date of birth). If Donor refuses to sign the certification statement, Collector enters a remark in STEP 2 on Copy 1.

STEP 4:

• 1 Collector completes STEP 4 on Copy 1 (signature, printed name, date, time of collection, and name of delivery service), places the sealed specimen bottle(s)`and Copy 1 of the. CCF in a leak-proof plastic bag, seals the bag, prepares the specimen package for shipment, and distributes the remaining CCF copies as required.

Privacy Act Statement: (For Federal Employees Only) Submission of the information on the attached form is voluntary. However, incomplete submission of the informatien, refusal to provide a urine specimen, or

substitution or adulteration of a specimen may result in delay or denial of your application for employment/appointrnent or may result in *oval from the Federal service or other disciplinary action. 1 The authority for obtaining the urine specimen and identifying information contained herein is Executive Order 12564 ("Drug-Free Federal Workplace"), 5 U.S.C. Sec. 3301 (2), 5 U.S.C. Sec. 7301, and Section 503 of Public Law 100-71, 5 U.S.C. Sec. 7301 note. Under provisions of Executive Order 12564 and 5 U.S.C. 7301, test results may only be disclosed to agency officials on a need-to-know basis. This may include the agency Medical Review Officer (MRO), the administrator of the Employee Assistance Program, and a supervisor with authority to take adverse personnel action. This information may also be disclosed to a court where necessary to defend against a challenge to an adverse personnel action.

Submission of your SSN is not required by law and is voluntary. Your refusal to furnish your number will not result in the denial of any right, benefit, or privilege provided by law. Your SSN is solicited, pursuant to Executive Order 9397, for purposes of associating inforrnation in agency files relating to you and for purposes Of identifying the specimen provided for testing. If you refuse to indicate your SSN, a substitute number or other identifier will be assigned, as, required, to process the specimen.

Public Burden Statement: Ana gency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control

number. The OMB control number for this project is 0930-0158. Public reporting burden for this collection of information is estimated to average: 5 minutes/donor; 4 minutes/collector; 3 minutes/test facility; and 3 minutes/Medical Review Officer. Send comments regarding this burden estimate or any other aspect of this collectionof information, including suggestions for reduding this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, ' Maryland, 20857.

• Collector checks specimen temperature within 4 minutes after receiving the specimen from Donor, and marks the, appropriate temperature 13OX in STEP 2. If temptur6 is outside the acceptable range, Collector enters a remark' in STEP 2 and takes action

Erie'

a TRUEBLUE company

GENERAL EMPLOYMENT ACKNOWLEDGEMENT

I recognize that I am an employee of PlaneTechs, LLC ("PlaneTechs"), which is solely responsible for my wages, hours of work, benefits (if any), payroll taxes and workers' compensation insurance. I agree that I will not have any unauthorized contact with a client company while working on_a_temporar_y_assignment with PlaneTechs. I also agree_that _I will not seek, nor_will I accept, employment from any_client company without the expressed consent of PlaneTechs. I acknowledge I will not be eligible for any benefit plan or wages from any client of PlaneTechs.

At-Will Employment. I hereby acknowledge that my employment is "at will" and not for a specific period of time, and that I may resign at any time and PlaneTechs may terminate my employment at any time with or without cause and with or without notice. I agree to hold PlaneTechs harmless from any claims including, but not limited to, personal injury or illness as a result of my providing false or misleading information on this application.

Confidentiality Statement. I understand that any information I learn while working for a client is to be kept confidential. Any information that has not been disclosed publicly in writing should be treated as confidential and proprietary. Failure to comply with instructions of supervisors or policies of the companies I am assigned to; incompetent work performance; unacceptable, immoral, aggressive or criminal conduct; failure to show up for or complete an assignment; and/or the use of, possession of or being under the influence of drugs and alcohol will result in disciplinary action up to and including termination of employment.

DISPUTE RESOLUTION

Agreement to Arbitrate. PlaneTechs and I agree that for any claim arising out of or relating to my employment, application for employment, and/or termination of employment, this Agreement, or the breach of this Agreement, shall be submitted to and resolved by binding individual arbitration under the Federal Arbitration Act ("FAA"). PlaneTechs and I agree that all claims shall be submitted to arbitration including, but not limited to, claims based on any alleged violation of a constitution, or any federal, state, or local laws; Title VII claims of discrimination, harassment, retaliation, wrongful termination, wages, compensation due or violation of civil rights; or any claim based in tort, contract, or equity.

Scope of Arbitration. PlaneTechs and I agree that arbitration in no way limits the relief that any party may seek in the jurisdiction in which arbitration has been filed. PlaneTechs AND I AGREE THAT EACH MAY BRING CLAIMS AGAINST THE OTHER ONLY IN MY OR ITS INDIVIDUAL CAPACITY, AND NOT AS A PLAINTIFF OR CLASS MEMBER IN ANY PURPORTED CLASS ACTION, COLLECTIVE ACTION, OR REPRESENTATIVE PROCEEDING. Further, unless both PlaneTechs and I agree otherwise, the arbitrator may not consolidate more than one person's claims, and may not otherwise preside over any form of a representative or class proceeding. If this specific provision is found to be unenforceable, then the entirety of this arbitration provision shall be null and void. Notwithstanding the foregoing, either party may bring an individual action in small claims court.

Arbitration Procedure. Any arbitration between PlaneTechs and I will be administered by the American Arbitration Association ("AAA") under its Employment Arbitration rules then in effect. Unless PlaneTechs and I agree otherwise, any arbitration hearings will take place in the county (or parish) where I last worked for PlaneTechs. PlaneTechs will pay all AAA filing, administration, and arbitrator fees and costs for any arbitration. If, however, the arbitrator finds that either the substance of my claim or the relief sought in the Demand is frivolous or brought for an improper purpose (as measured by the standards set forth in Federal Rule of Civil Procedure 11(b)), then the arbitrator may award all fees and costs as per Rule 11 to PlaneTechs.

Claims Under $10,000. If my demand for arbitration is for $10,000 or less, PlaneTechs will promptly reimburse me for my payment of any filing fee for arbitration, and we agree that I may choose whether the arbitration will be conducted solely on the basis of documents submitted to the arbitrator, through a telephonic hearing, or by an in-person hearing as established by the AAA Rules. Also, if after a finding in my favor in any respect on the merits of my claim, the arbitrator issues me an award that is greater than the value of PlaneTechs' last written settlement offer made, then PlaneTechs will: (1) pay me the amount of the award or $10,000, whichever is greater; and (2) pay my attorney, and reimburse any expenses (including expert witness fees and costs) that my attorney reasonably accrues for investigating, preparing, and pursuing my claim in arbitration.

Statute Of Limitations. PlaneTechs and I agree that any claims arising out of or relating to this Agreement, the breach of this Agreement, or my application, employment, or termination of employment, shall be submitted to arbitration, or filed with a court of competent jurisdiction where arbitration is not permitted by law, within one year (365 days) of the act, omission, breach, or violation that gives rise to any claim, including, but not limited to, claims based on any alleged violation of federal or state law; violation of civil rights; or any claim based in tort, contract, or equity.

Name (Please Print): MATH /rn S PAN. A C ORM

Signature:

Date: 3 - 31- 2015

Page 1

PRE-EMPLOYMENT URINALYSIS NOTIFICATION FORM

I understand as a pre-qualification condition, I am required by 49 CFR Part 40, as amended, and 14 CFR Part 120, Department of Transportation, Federal Aviation Administration Regulations, to submit to a controlled substance test.

I agree to provide a urine sample at a location and time designated by PlaneTechs LLC, to be tested for controlled substances.

I understand that the specific drugs I am being tested for are: Marijuana, Cocaine, Phencyclidine (PCP), Amphetamines, and Opiates or a metabolite of these drugs.

I understand if I test positive for use of controlled substances I am not medically qualified to perform in a safety sensitive function.

The results of the controlled substances tests will be maintained by PlaneTechs LLC's designated Medical Review Officer who will report to PlaneTechs LLC whether the test results were negative or positive. I authorize PlaneTechs LLC or the Medical Review Officer to release the test results to the examining medical physician to assist in determining if I am medically qualified to perform in a safety sensitive function. The results will not be released to any additional party without my written authorization.

I agree to submit to the required controlled substance urinalysis.

MA T 41 AS &LA CoRIVI Applicant's printed name

03- 31- 201g

App can 's Signature

Date Signed

FM-DOT

Page 4

Employment Eligibility Verification

Department of Homeland Security U.S. Citizenship and Immigration Services

USCIS Form 1-9

OMB No. 1615-0047 Expires 03/31/2016

►START HERE. Read instructions carefully before completing this form. The instructions must be available during completion of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form 1-9 no later than the first ay ofiT—nployment, but not before accepting a job offer)—

Last Name (Family Name) First Name (Given Name) Middletejnitlal

C ORO A M ItTli 1AS

Other Names Used (if any)

Address (Street Number and Name)

510 6 SAGE C.+.

Apt. Number City or Town

141Y1 ANA Pal S

State

/4

Zip Code

46237 Date of Birth (mm/dd/yyyy)

Og/13/1q88

U.S. Social Security Number E-mail Address

re) 0. iz 130 klefrnet; I * er"A

Telephone Number

311-'160-0103 315 - 25- 4366 Matt1Co

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):

21 A citizen of the United States

❑ A noncitizen national of the United States (See instructions)

❑ A lawful permanent resident (Alien Registration Number/USCIS Number):

❑ An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy) . Some aliens may write "N/A" in this field. (See instructions)

For aliens authorized to work, provide your Alien Registration Number/USCIS Number OR Form 1-94 Admission Number:

1. Alien Registration Number/USCIS Number:

OR 2. Form 1-94 Admission Number:

If you obtained your admission number from CBP in connection with your arrival in the United States, include the following:

Foreign Passport Number:

Country of Issuance:

Some aliens may write "N/A" on the Foreign Passport Number and Country of Issuance fields. (See instructions)

3-D Barcode Do Not Write In This Space

Signature of Employee: g,4, 6.1,L9et. Date (mm/ddlyyYY): 03 _ 31 - 201S

Preparer and/or Translator Certification (To be completed and signed if Section 1 Is prepared by a person other than the employee)

I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct.

Signature of Preparer or Translator: Date (mm/dd/yyyy):

Last Name (Family Name) First Name (Given Name)

Address (Street Number and Name) City or Town State Zip Code

STOP

Employer Completes Next Page

STOP

Form 1-9 03/08/13 N

Page 13

Signature of Employer or Authorized Representative

Date (mmIddlyyyy)

Title of Employer or Authorized Representative

Last Name (Family Name)

First Name (Given Name)

Employer's Business or Organization Name

PlaneTechs

Employer's Business or Organization Address (Street Number and Name) City or Town State Zip Code

1520 Kensington Road, Suite 311 Oak Brook IL 60523

Er'

Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR examine a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents" on the next page of this form. For each document you review, recent the following Information: document title, issuing authority, document number, and expiration date, If any.)

Employee Last Name, First Name and Middle Initial from Section 1: ColeoA mityrtims, P List A OR

List B

AND

List C Identity andEmployment Authorization Identity Employment Authorization

Document Title:

Driver LicestsE Document Title: Document Title:

Issuing Authority:

IN issuing Authority: Issuing Authority:

Document Number

Sliio - 01- 93-78 Document Number: Document Number.

Expiration Date (if any)(mm/ddlyyyy).

og hs 1201-7 Expiration Date (if any)(mm/ddlyyyy): Expiration Date (If any)(mmIddlyyyy);

Document Title:

Issuing Authority:

Document Number.

Expiration Date (If any)(nvn/ddlyyyy):

3.0 Barcode Do Not Write In This Space Document Title:

Issuing Authority:

Document Number.

Expiration Date (if any)(mm/ddlyyyy

Certification I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States.

The employee's first day of employment (mm/dd/yyyy):

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.) A. New Name (if applicable) Last Name (Family Name) First Name (Given Name) Middle initial B. Date of Rehire (if applicable) (mmIrld/yyyy):

C. It employee's previous grant of employment authorization has expired, provide the Information for the document from List A or List C the employee presented that establishes current employment authorization In the space provided below.

Document Title:

Document Number. Expiration Date (If any)(mm/ddlyyyy):

I attest, under penalty of perjury, that to the best of my knowledge, this employee Is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.

Signature of Employer or Authorized Representative:

Date (mm/dd/yyyy):

Print Name of Employer or Authorized Representative:

Form 1.9 03'08'13 N

Page 14

(See Instructions for exemptions.)

1 Your first name and middle Initial

Form W-4 (2015) Purpose. Complete Form W-4 so that your employer can withhold the correct federal Income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes. Exemption from withholding. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2015 expires February 16, 2016. See Pub. 505, Tax Withholding and Estimated Tax. Note. If another person can claim you as a dependent on his or her tax return, you cannot claim exemption from withholding if your income exceeds $1,050 and includes more than $350 of unearned Income (for example, Interest and dividends).

Exceptions. An employee may be able to claim exemption from withholding even If the employee Is a dependent, If the employee: • Is age 65 or older,

• Is blind, or

• Will claim adjustments to income; tax credits; or itemized deductions, on his or her tax return.

The exceptions do not apply to supplemental wages greeter than $1,000,000. Basic instructions. If you are not exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding allowances based on itemized deductions, certain credits, adjustments to Income, or two-earners/multiple jobs situations.

Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages. Head of household. Generally, you can claim head of household filing status on your tax return only If you are unmarried and pay more than 60% of the costs of keeping up home for yourself and your dependent(s) or other qualifying Individuals. See Pub. 601, Exemptions, Standard Deduction, and Filing information, for information. Tax credits. You can take projected tax credits into account In figuring your allowable number of withholding allowances. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below. See Pub. 505 for Information on converting your other credits Into withholding allowances.

Nomvage income. if you have a large amount of nonwage income, such as Interest or dividends, consider making estimated tax payments using Form 1040•ES, Estimated Tax for Individuals. Otherwise, you may owe additional tax. If you have pension or annuity income, see Pub. 605 to find out If you should adjust your withholding on Form W-4 or W-4P. Two earners or multiple Jobs. If you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all Jobs using worksheets from only one Form W-4, Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying Job and zero allowances are claimed on the others. See Pub. 505 for details. Nonresident alien. If you are a nonresident alien, see Notice 1392, Supplemental Form W-4 instructions for Nonresident Aliens, before completing this form. Check your withholding. After your Form W-4 takes effect, use Pub. 505 to see how the amount you are having withheld compares to your projected total tax for 2015. See Pub. 605, especially If your earnings exceed $130,000 (Single) or $180,000 (Manied). Future developments. information about any future developments affecting Form W-4 (such as legislation enacted after we release It) will be posted at www.irs.gorlw4.

Personal Allowances Worksheet (Keep for your records.) A Enter "1" for yourself if no one else can claim you as a dependent

{ • You are single and have only one job; or

B Enter "1" if: • 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.

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.) 10 . H

• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions For accuracy, and Adjustments Workeheet 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.

A

Separate here and give Form W-4 to your employer. Keep the top part for your records.

Employee's Withholding Allowance Certificate ► Whether you are entitled to claim a certain number of allowances or exemption from withholding Is subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

Form W-4 Department of the Treasury Internal Revenue Service

OMB No. 1545-0074

2015

Home address (number and street or rural route

Itelainnapilm- Lt0Z37 5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 6 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 liabili 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.) ► /4_4p, ,iy

8 Employer's name and address (Employer: mplete lines 8 and 10 only if sending to the IRS.) 9 Office code (optional)

For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 102200

Form W-4 (2015) Page 16

57o6 SAGE c+, 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. Ia. 0

2 Your social security number

31 - 2 5 - 4-36 5 3 ❑ Single Married ❑ Married, but withhold at higher Single rate.

Note. If married, but legally separated, or spouse Is e nonresident alien, check the 'Single" box.

Date t• (:)3 — 21 - zois.

10 Employer Identification number (EIN)

Form W-4 (2015) e2 ..

Deductions and Adjustments Worksheet Note. Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments

1 Enter an estimate of your 2015 Itemized deductions. These include qualifying home mortgage interest, charitable contributions, and local taxes, medical expenses In excess of 10% (7.5% If either you or your spouse was born before January 2, 1951' income, and miscellaneous deductions. For 2015, you may have to reduce your itemized deductions if your income is over and you are married filing jointly or are a qualifying widow(er); $284,050 if you are head of household; $258,250 if you are single head of household or a qualifying widow(er); or $154,950 if you are married filing separately. See Pub. 505 for details .

to income.

state of your

8309,900 and not

. . . 1 $

2 Enter: 1 $12,600 if married filing jointly or qualifying widow(er) $9,250 if head of household

1 2 $

$6,300 if single or married filing separately 3 Subtract line 2 from line 1. If zero or less, enter "-0-" 3 $ 4 Enter an estimate of your 2015 adjustments to income and any additional standard deduction (see Pub. 505) 4 $ 5 Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to

Withholding Allowances for 2015 Form W-4 worksheet In Pub. 505.) 5 $ 6 Enter an estimate of your 2015 nonwage income (such as dividends or interest) 6 $ 7 Subtract line 6 from line 5. If zero or less, enter "-0-" 7 $ 8 Divide the amount on line 7 by $4,000 and enter the result here. Drop any fraction 8 9 Enter the number from the Personal Allowances Worksheet, line H, page 1 9

10 Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Muttiple Jobs Worksheet, also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1 io

Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.) Note. Use this worksheet only if the instructions under line H on page 1 direct you here.

1 Enter the number from line H, page 1 (or from line 10 above If you used the Deductions and Adjustments Worksheet) 1 2 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if

you are married filing jointly and wages from the highest paying Job are $65,000 or less, do not enter than "3"

more

2 3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter

"-0-") and on Form W-4, line 5, page 1. Do not use the rest of this worksheet 3 Note. If line 1 is less than line 2, enter "-0-" on Form W-4, line 5, page 1. Complete lines 4 through 9 below to

figure the additional withholding amount necessary to avoid a year-end tax bill.

4 Enter the number from line 2 of this worksheet 4 5 Enter the number from line 1 of this worksheet 6 Subtract line 5 from line 4

5

6 7 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . • 7 $ 8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . . 8 $ 9 Divide line 8 by the number of pay periods remaining in 2015. For example, divide by 25 if you are paid every two

weeks and you complete this form on a date in January when there are 25 pay periods remaining in 2015. Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck 9 $

Table 'I Table 2 Married Filing Jointly All Others Married Filing Jointly All Others

If wages from LOWEST Enter on if wages from LOWEST Enter on if wages from HIGHEST Enter on if wages from HIGHEST Enter on paying Job are- line 2 above paying job are- line 2 above paying Job are- line 7 above paying Job are- line 7 above

$0 - $6,000 0 $0 - $8,000 0 $0 - $75,000 $600 $0 - $38,000 $600 8,001 - 13,000 1 8,001 - 17,000 1 75,001 - 135,000 1,000 38,001 - 83,000 1,000

13,001 - 24,000 2 17,001 - 26,000 2 135,001 - 205,000 1,120 83,001 - 180,000 1,120 24,001 - 26,000 3 26,001 - 34,000 3 205,001 - 360,000 1,320 180,001 - 395,000 1,320 26,001 - 34,000 4 34,001 - 44,000 4 360,001 - 405,000 1,400 395,001 and over 1,580 34,001 - 44,000 5 44,001 - 75,000 5 405,001 and over 1,580 44,001 - 50,000 6 75,001 - 85,000 6 50,001 - 65,000 7 85,001 - 110,000 7 65,001 - 75,000 8 110,001 - 125,000 8 75,001 - 80,000 9 125,001 - 140,000 9 80,001 - 100,000 10 140,001 and over 10

100,001 - 115,000 11 115,001 - 130,000 12 130,001 - 140,000 13 140,001 - 150,000 14 150,001 and over 16

Privacy Act and Paperwork Reduction Act Notice. We ask for the Information on this form to carry out the internal Revenue laws of the United States. Internal Revenue Code sections 3402(0(2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal Income tax withholding. Failure to provide a properly completed form wit result In your being treated as a single person who claims no withholding allowances; providing fraudulent Information may subject you to penalties. Routine uses of this Information Include giving it to the Department of Justice for chit and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use In administering their tax laws; and to the Department of Health and Human Services for use In the National Directory of New Hires. We may also disclose this Information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and Intelligence agencies to combat terrorism.

You are not required to provide the Information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or Its Instructions must be retained as long as their contents may become material In the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section 6103.

The average time and expenses required to complete and file this form will vary depending on Individual circumstances. For estimated averages, see the Instructions for your Income tax retum.

If you have suggestions for making this form simpler, we would be happy to hear from you. See the Instructions for your Income tax return.

Page 17

EMERGENCY CONTACT

Name: MARTin ► l co1ao4 .

Local Contact Number: 3 11- 52 5-73 Lt.

Please provide the two most accessible people that you would like PlaneTechs to contact in case of an emergency:

Primary Contact Person

Relation: Husbarld.

First Name: Vicfor Mavis e] Last Name: Lo9 Vac .

Contact Number 1: 311- 205 -- 6773

Contact Number 2:

Email:

Secondary Contact

Relation: Dad

First Name: Luis Ricat-do . Last Name: CoRo#1

Contact Number 1: 311 - 3 - I0 S-7

Contact Number 2:

Email:

Page 18

...gal lot a TRUEBUJE company

CERTIFICATION OF PER DIEM SUBSTANTIATION REQUIREMENTS

My legal name (print) is MATH IAS PAOLA- CO R0A and I make the representations, agreements, and statements herein to certify my eligibility to receive a per diem allowance from PlaneTechs. If I receive a per diem allowance, I understand that the allowance payments are solely to reimburse me for lodging, meal, and incidental expenses that I incur, or which reasonably I may incur, in connection with the performance of services as a contract worker of PlaneTechs while temporarily away from the locality of my principal residence. Thus, I understand and agree that my per diem allowance is not a wage. I understand that any per diem allowance will be reduced in proportion to the number of workdays, as may be defined by PlaneTechs, which I do not devote to the business of PlaneTechs. I also am aware that my per diem allowance must not exceed the rates authorized by the federal Internal Revenue Service (IRS). I request that any per diem allowance I receive be characterized as non-taxable reimbursements on my payroll documents. I understand that any per diem allowance provided by PlaneTechs to me will be in consideration of, and reliance upon, my agreements, representations, and statements herein.

To affirm my eligibility to receive a per diem allowance, I represent that the following is true:

1. My principal residence and tax home as defined by the IRS is located here:

Street Address: 5106 SAGE c+.

City, State, & Zip Code: 'Minna pot;. in/ - Lfb23 7

Telephone Number: 311- 760- 0103

2. I perform a principal portion of my business within the locality of my principal residence when residing at my principal residence.

3. I incur duplicate expenses if or when PlaneTechs places me in an assignment away from the locality of my principal residence.

4. Members of my family (marital or lineal) reside at my principal residence, or if I am single, I use my principal residence frequently for lodging.

5. The locality of my current (or upcoming) assignment is at Mar ;on . and I anticipate that it is a temporary assignment which will not, when complete, have caused or required me to reside or work in this locality for more than one year.

6. The distance of the locality of my assignment from my principal residence is such that I cannot reasonably commute between my principal residence and my assignment.

I agree to inform PlaneTechs immediately in writing if any of the information or understandings I represent, state, or agree to herein change. I agree to complete a new certification whenever PlaneTechs requests that I do so.

I ACKNOWLEDGE THAT PLANETECHS RELIES UPON THE ABOVE REPRESENTATIONS, AGREEMENTS, AND STATEMENTS FOR THE PURPOSE OF REMITTING PER DIEM ALLOWANCES. THEREFORE, TO THE EXTENT ALLOWED BY LAW, I WILL HOLD HARMLESS, DEFEND, AND INDEMNIFY PLANETECHS FROM ANY CLAIMS, COMPLAINTS, PENALTIES, BACK TAXES, DAMAGES, COSTS, AND INTEREST WHICH MAY BE ASSESSED, SOUGHT, OR BROUGHT AGAINST PLANETECHS THAT IN ANY WAY RELATE TO OR ARISE FROM (A) AN INCORRECT OR FALSE REPRESENTATION OR STATEMENT HEREIN OR (B) A BREACH BY ME OF AN AGREEMENT HEREIN.

Under penalties of perjury, I declare that I have examined the foregoing and, to the best of my knowledge and belief, it is true, correct, and complete.

Signed: 12_044 G.71.0c, Date: p A - 31- 2015 SSN: 315 - "zs - 4-3(05

Page 19

In case of a work related injury

INFORM PLANETECHS IMMEDIATELY!

Contact your PlaneTechs on-site representative first.

If your site doesn't have an on-site rep, please inform your recruiter.

REMEMBER: Please follow all safety procedures.

If you work safely, you won't need this card.

O

RECEIPT OF THE WORKMAN'S COMP INFORMATION CARD

I, MirMIAs PA.M.A- 032o/3r have received the PlaneTechs Workers Comp Information wallet card. I have been instructed by my coordinator or recruiter in the proper procedures to follow in case of a work related injury. I understand that if I do not follow the proper procedures that my claim may be denied by the State and the Insurance Company. I also acknowledge that in the event of a work related injury I cannot return to work until I have reported to my Coordinator, or in the case of a site without a coordinator I must check in with the PlaneTechs Worker's Comp office. Under no circumstances may I work FAA related duties if taking medication which could have a negative effect on my ability to work safely or is prohibitive under the FARs and/or OSHA regulations. This includes medications either prescribed by a doctor or purchased over the counter. I understand that any restrictions placed on me by the physician must be reviewed by the PlaneTechs Workers Comp office who must then make contact with the appropriate Floor Supervisor, Manager and Human Recourses Manager to determine if I can be used by this site within the limits of said restrictions. I understand that working with restrictions without obtaining the consent of the Workers Comp office and the Site HR department may result in my termination from that site.

REPORT ANY WORK RELATED INJURY TO YOUR PLANETECHS ON-SITE REP.

An injury must be reported to PlaneTechs immediately to be covered by Workers' Compensation insurance.

FAILURE TO FOLLOW CORRECT PROCEDURES COULD RESULT IN A DENIAL OF YOUR CLAIM. If you feel you may need medical attention, please call:

11-888.454.6272 Direct all questions or concerns to your on-site rep OR

PlaneTechs' Workers' Compensation Department. Toll Free Phone: 1-800-669-5627, ext. 219

Secure Fax: 1-815-301-1806

I acknowledge that the image above is a reasonable facsimile of the card I received.

Print Full Legal Name: MA-171 figs PAOLA coizzA •

Signature: fr.old.. CtolArr4. Date: 03 31- 2016

Page 20

EMPLOYEE BRIEFING What to do in case of a work related injury

1. If you've had a work related injury which you feel must be seen by a physician, call the 24/7 nurse at 1-888-454-6272 before going for medical treatment. The only exception would be a life threatening injury. If you do not feel the need for medical treatment Contact your recruiter at the home office to file a report only at that time.

Not every scratch needs or should be reported; use good common sense.

2. You will have to fill out the PlaneTechs First Report of Incident prior to going for treatment unless the injury is life threatening.

3. Once you declare a Workman's Comp incident, we will notify the site HR Director and your Department Manager that you'll be off work until all State, Federal, and Site specific Contract requirements have been met.

4. REMEMBER: If you feel you need to seek medical treatment, before you can return to duty you will a need a full medical release, along with the mandatory Post incident Drug and Alcohol test documentation. All of the required documents must be faxed or E-mailed to the PlaneTechs Workman's Comp office at 815-301-1806 or SALewisAplanetechs.com . It will be reviewed by the Director of Workman's Compensation who will then determine if you will be authorized to return to work.

YOU CANNOT JUST COME BACK WITHOUT PROPER CLEARANCE

5. If the treating facility puts you on any restrictions we may not be able to allow you to return to work. We will try and work with the Site Manager at your site to find work. However remember since you are a contractor (a Temp and not a direct employee of the Site) they might not be able to accommodate your restrictions. The average time before an unrestricted release is issued has been 7 days. There is no compensation (Pay) until that particular States waiting period has pasted, an average of 8 days. Should you be out long enough to qualify for pay under Workman's Comp, remember on average the State Workman's Compensation for wages will only be 2/3s of your Taxable wage; Per-diem (if any) will not be considered towards your benefits.

6. You must contact the PlaneTechs Workman's Comp office after each medical visit and keep us advised of your medical status and send any paperwork to the PlaneTechs/TransTechs Fax or E-mail listed above. Please remember that if you are looking for an authorization to return to work that day or if it is a Friday and you are hoping for authorization to return to work that weekend; the paperwork to be considered must reach the Director of Workman's Compensation before 2:00 PM Central Time Monday thru Friday. We do not review paperwork on the weekend, or before 09:00 AM Central Time Monday through Friday.

7. Only the PlaneTechs Corporate Office can authorize your return to work; your lead, supervisor, or even the site coordinator can NOT authorize your return to work.

If you violate Company policy and return to work without following proper procedures, you could be in violation of Federal Law and subject to termination.

If you have questions about these regulations, you may call the PlaneTechs Workman's Comp Office at 1-800-669-5627 x 219

Print Full Legal Name: MATH I A S PAOLA CO RDA

Signature: 4..., CA.71,1,0,-- Signature:} Date: 03- 31-2015

Page 21

tg a TRUEBLIIE comr-my

is • • • CITY

Address: 5706 SAG STREET

Hire Date: 04— oG - 2015

1.142237 STATE ZIP CODE

Employment Status: ( ) Temporary

EMPLOYMENT NOTICE

Name of Employee: MATH IRS 'PAOLA C6126A PLEASE PRINT

SCHEDULDED HIRE DATE

Hours may vary subject to demands of the business. This does not constitute a guarantee of hours to be worked. Part time and temporary employees are scheduled as needed.

Wages will be paid hourly at a minimum rate of no less than $7.25 per hour unless otherwise specified by PlaneTechs. All wages will be paid in accordance with all State and Federal Laws.

Employee may be eligible to receive overtime pay. Eligibility for overtime pay and the overtime rate of pay will be determined in accordance with all State and Federal Laws.

Pay period: Weekly on each Friday of the week.

PlaneTechs offers its employees various options for payment of wages including direct deposit, payroll debit cards and paychecks. Payment will be paid electronically or will be available at your local client location depending on the payment option chosen.

Advance requests can be performed on Mondays or Wednesdays. PlaneTechs only allows two advances per site and there is a $25 fee per advance request. The maximum advance amount is $200, and the contractor must have worked 20 hours (contractor must have worked 10 hours for a $100 advance). Hours worked must be verified by the onsite coordinator or supervisor.

I certify that I have been advised of the above and agree that:

The company reserves the right to deduct from an employee's wage for any company debt or obligation such as, but not limited to, employee loans/advances, employee elected insurance premiums, court ordered wage garnishments, or any loss or damage of company property. Deductions will only be made as permitted under state and federal Wage and Hour regulations.

Employer Signature Date

CV-Leo s- • o3 - 3 I-2015

Employee Signature Date

Page 22

a TRUEBLUE nimpany DIRECT DEPOSIT ENROLLMENT

To enroll in FULL SERVICE DIRECT DEPOSIT, simply fill out this form and give it to your payroll manager. Please attach a voided check for each checking account listed - Not a deposit slip. If depositing to a savings account, ask your bank to give you a bank letter stating your routing/transit number and account number. This will help ensure you are paid correctly.

**Must provide a Voided Check or Bank Letter for direct deposit to be processed!

Account Information

1. Bank Name/City, State: TC U / Indiaoapo l is ND; ANA

Checking I wish to deposit: $ or

Entire Net Amount

(DO NOT ENTER PERCENTAGE)

2. Bank Name/City, State:

Checking

I wish to deposit: $ or

Entire Net Amount



Savings


Entire Net Amount



Savings


Entire Net Amount


*** PLEASE NOTE THAT DIRECT DEPOSIT CAN ONLY BE TERMINATED PER WRITTEN REQUEST. SEE ATTACHED DIRECT DEPOSIT TERMINATION FORM FOR INSTRUCTIONS. IT IS YOUR RESPONSIBILITY TO INFORM PLANETECHS OF ANY ACCOUNT CHANGES.

Important! Please read and sign before completing and submitting.

I hereby authorize my employer, PlaneTechs, to deposit any amounts owed me by initiating credit entries to my accounts at the financial institutions indicated on this form. Further, I authorize Bank to accept and to credit any credit entries indicated by PlaneTechs to my accounts. In the event that PlaneTechs deposits funds erroneously into my account, I authorize PlaneTechs 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 PlaneTechs has received written notice from me of its termination in such time and in such manner as to afford PlaneTechs reasonable opportunity to act on it.

Employee Name: MATH IAS -Noui Coa0/1 Social Security # 315- 25 - 4365

Employee Signature: i tehdv-

r"-b—Ot, Date: 03 - 31- 2.016"

Page 26

APPLICATION & RELEASE FORM

hiclictoopol is County

IN/ Country

a TRUEBLUE company

If this form is not filled out completely, and in a manner that can be read clearly, it cannot be processed and could affect your ability to obtain employment with PlaneTechs.

Social Security #: 3

5 2 5 4 3 Date of Birth:

0

3 q g

(MM-DD-YYYY) First Name (no nicknames

Middle Initial

M A

S

P Last Name

Suffix

C

Iz 0 Maiden or Other Name Formerly Used

A

L A Date Last Used (MM-YY

EEO IDENTIFICATION

It is the policy of PlaneTechs to provide equal employment opportunities to all qualified applicants and employees regardless of race, color, sex, religion, national origin, disability, veteran status, age, marital status or any other protected group. Your completion of this information is voluntary and is requested to meet record keeping and affirmative action requirements.

Sex: * ❑ Male ErFemale (* Some jurisdictions require this information to process a requested search)

Race: * ❑ White ❑ Black/African American ❑ Asian ❑ American Indian/Alaskan Native ❑ Native Hawaiian/Pacific Islander ❑ Two or more races ❑ Other (please specify):

Ethnicity: * 12(Hispanic/Latino

DisabledNeteran Status:

❑ Disabled Person ❑ Special Disabled Veteran

❑ Vietnam Era Veteran ❑ Other Protected Veteran

LICENSE INFORMATION

Date Issued: 08 - 19- 201 .4 Expiration Date: 08 -13- 201-1 Issuing State: Ihibi A-NA

Driver's License Number:

4

0

0

3 1 A & P License Number:

FCC License Number:

PERMANENT ADDRESS Street

Apt. No.

5706 SAGE C+

1-14, 23 7 City

State

Zip

MARion/

USA-• Dates at address: FROM: (MM-DD-YY)

- I

TO: (MM-DD-YY)

Page 33

Street 51 0 (9 SA 6e Apt. No.

MAgioni

State /eV Country

USA .

Zip 4-6 Z3 City 10dialiapolis

County

Apt. No. Street

Zip State City

Country County

Apt. No. Street

Zip State City

Country County

Apt. No. Street

Zip State City

Country County

Apt. No. Street

Zip State City

Country County

RESIDENTIAL HISTORY (List all other cities/counties where you have lived in the last 10 years starting with the most recent):

Dates at address: FROM: (MM-DD-YY)

TO: (MM-DD-YY)


TO: (MM-DD-YY)

Street

Apt. No.

City

State

Zip

County

Country


TO: (MM-DD-YY)


TO: (MM-DD-YY)


ElE1

TO: (MM-DD-YY)


TO: (MM-DD-YY)

Page 34

2 0 8 Start Date (MM-DD-YY):

3

2. 3 0

End Date (MM-DD-YY):

0

Start Date (MM-DD-YY

0

2. 0

End Date MM-DD-YY):

2

Start Date (MM-DD-YY

5.

EMPLOYMENT INFORMATION Begin with most current - 10 year history required

A records check will be performed on the previous 2 years of DOT regulated employment; including current employers

Type of Employment to Verify: I1Current ❑ Previous ❑ School 1=1 Self ❑ Unemployment 1=1 Military

Company Name ' AEROSPACE SAN] AN -I-Dal 0

Phone Number

Street 9 960 airport gLv.

City State SAN/ ii-Nato rs.0 ' 0 TEXAS

Zip Code 18216

Contracting Firm -,- JoBAi(E

Phone Number (2i0) $11 -3115

Street City State _SAN ANIDnlio TEXAS

Zip Code

Type of Work and Plane .8 .73 -1 , 815-7 161 E-110,1 -75

Position/Title m EaMplici 11 ei teriar4

Reference City & State Phone Number

Start Date (MM-DD-YY :

End Date MM-DD-YY :

5

Type of Employment to Verify: 111 Current 2 Previous 1=1 School 111 Self ❑ Unemployment ❑ Military

Company Name I- -rga 0

/ Air•orf dkio 0

Phone Number

Street 7800 COL .11. WPM_ COOK

ity State MEmoaiAL DrIve. 1W

Zip Code 116241

Contracting Firm Air Sery .

Phone Number

Street City State Zip Code

Type of Work and Plane " b -151 1 R1-1 1

Position/Title, Uenpval aircraft cleaner.

Reference 8-1r1

City & State Phone Number

Type of Employment to Verify: 111 Current F2r Previous ❑ School 111 Self 111 Unemployment ❑ Military

Company Name 1111-0LEX

Phone Number

Street NA,

City State I14

Zip Code

Contracting Firm 13enefit ReS6urCeS INC

Phone Number


Type of Work and Plane of ' i g .1 Miti+Or I i cr• , a

Position/Title


Type of Employment to Verify: ❑ Current 12 Previous 111 School ❑ Self ❑ Unemployment 111 Military

Company Name A t IZOS P A cP Savrta baybava

Phone Number

Street sA la .

City State Zip Code

Contracting Firm .can-Fa &iv bal CA

Phone Number


Type of Work and Plane , h1517-200 il-Wirzoo P)761 De ci 1 bCIO

Position/Title ioferiors wcalinfic


Page 35

PREVIOUS EMPLOYER: COMPANY LOCATION (CITY/ STATE): PHONE/FAX #: EMPLOYMENT DATES: PHONE:

FAX:

DRUG & ALCOHOL RECORDS CHECK 49 CFR Part 40

EMPLOYMENT AUTHORIZATION RELEASE

Section I: To be completed and signed by the applicant. Please return to PlaneTechs with the rest of the application paperwork.

Employee's Printed Name: Mitrttl A S F'Ao LA Co itoPt Employee SSN: 315 ̂ 25 ° 4 3 6C5

I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my

previous employer to PlaneTechs, and its agent BackTrack. This release is in accordance with DOT Regulation 49 CFR Part 40, Section 40.25. I understand that information to be released by my previous employer, is limited to the following DOT-regulated items: alcohol tests with a result of 0.04 or higher, verified positive drug tests, refusals to be tested, other violations of DOT agency drug and alcohol testing regulations, information obtained from previous employers of a drug and alcohol rule violation and any documentation of completion of the return-to-duty process following a rule violation. The following information is required by law enforcement agencies and other entities for positive identification purposes when checking public records. It is confidential and will not be used for any other purposes. I also hereby authorize any of my former employers and/or educational institutions to furnish PlaneTechs, and its agent BackTrack, with any information they may have concerning me, and do hereby release such employers and/or educational institutions from all liability in connection with issuing such information.

Employee Signature: 1.."1.-11 arcar,, Date: 03 - SI - 2015

Section II: To be completed by the current employer.

CURRENT EMPLOYER: COMPANY ADDRESS: PHONE #: FAX #:

PlaneTechs, LLC 1520 Kensington Rd. Suite 311

Oak Brook, IL 60523 BackTrack

1-800-991-9694 BackTrack

1-866-352-7127

Section III: To be completed by the previous employer & transmitted by mail/fax to the new employer's agent.

III-A: In the previous two years prior to the date of the employee's signature (in Section 1), for DOT-regulated testing:

1. Did the employee have alcohol tests with a result of 0.04 or higher? YES NO

2. Did the employee have a verified positive drug test? YES NO

3. Did the employee refuse to be tested?

YES_ NO

4. Did the employee have other violation of DOT agency drug and YES NO alcohol testing regulations?

5. Did a previous employer report a drug and alcohol rule violation? YES NO

6. If you answered "yes" to any of the above items, did the employee YES NO N/A complete the return-to-duty process?

Note: If you answered "yes" to item 5, you must provide the previous employer's report. If you answered "yes" to item 6, you must also transmit the appropriate return-to-duty documentation.

III-B: Dates of Employment: to Position:

Name of person providing the information in Section II-A:

Title: Phone Number:

Signature: Date:

Page 37

NOTICE AND ACKNOWLEDGMENT AUTHORIZATION RELEASE

Within the past ten (10) years have you been convicted of a crime that has not been expunged from your record? (Include offenses for which you served probation, paid a fine and/or served a jail sentence.) Or are you currently on probation or parole for a criminal offense or have you received an alternative disposition sentence for a criminal act?

/NO ❑ YES If yes, fill in below: ,'NO ❑ YES This conviction is classified as a Felony or Indictable Offense.

Date City State

Details

NOTE: You are not obligated to disclose sealed, annulled or expunged, statutorily eradicated convictions or convictions pardoned by the governor, dismissed under the First Offender's law, or convictions which state law allows you to lawfully deny as set forth below. Please be aware that a criminal conviction will not necessarily be a bar to employment and will be considered as it relates to the job in question. Factors such as your age at the time of conviction, how long ago it occurred, the reason for the conviction and the rehabilitation you received will all be considered. Failure to honestly and completely answer the above questions (other than as described below) can result in discontinued consideration of the application or termination of employment. Please be advised that the nature and scope of this investigative consumer report obtained with regard to applicants for employment is conducted by BackTrack, Inc., 8850 Tyler Boulevard, Mentor, OH 44060. *CALIFORNIA applicants/residents only: You need not disclose any referral to, and participation in, any pre-trial or post-trial diversion program, or any misdemeanor convictions for which probation has been successfully completed and discharged. Do not list any marijuana-related misdemeanor convictions over two-years old. By signing below, you also acknowledge receipt of the notice regarding background investigation pursuant to California Law. *CONNECTICUT applicants/residents only: You need not disclose any conviction record that has been erased pursuant to sections 46b-146, 54-76o or 54-142a of the Connecticut General Statutes. Records subject to erasure under these sections are records pertaining to a finding of delinquency or that a child was a member of a family with service needs, an adjudication as a youthful offender, a criminal charge that was dismissed or nolled, or a criminal charge for which the person was found not guilty or received an absolute pardoned conviction. Any person whose records were erased within the meaning of these three sections may consider such events to have never occurred and may so swear under oath. *HAWAII applicants/residents only. Do not respond to this question until you have been given a conditional offer of employment. *KENTUCKY applicants/residents only. You do not respond "Yes" as a result of any misdemeanor conviction where the date of conviction was more than five years ago. *MASSACHUSETTS applicants/residents only. Do not answer criminal history information on an initial application. If you have already completed an initial application, please note an applicant for employment with a sealed record on file with the commissioner of probation may answer "no" to the above with respect to an inquiry herein relative to prior arrests, criminal court appearances or convictions. In addition, any applicant for employment may answer "no" to the above with respect to any inquiry relative to prior arrests, court appearances and adjudications in all cases of delinquency or as a child in need of services which did not result in a complaint transferred to the superior court for criminal prosecution. You may exclude information regarding first convictions for the following misdemeanors: drunkenness, simple assault, speeding, minor traffic violations, affray, or disturbance of the peace, or a conviction for any misdemeanor where the conviction occurred or any prison sentence ended five or more years ago whichever date is later, unless you have been convicted of another offense within the last 5 years. * OREGON applicants/residents only: Information describing your rights under federal and Oregon law regarding consumer identity theft protection, the storage and disposal of your credit information, and remedies available should you suspect or find that the Company has not maintained secured records is available to you upon request. *WASHINGTON applicants/residents only. You may exclude convictions that occurred over ten years ago.

I certify that the information contained herein is true and understand that any falsification will result in the rejection of my application or termination of my employment. I also understand that the requested information is for the sole purpose of conducting a background investigation which may include a check of my identity (including my Social Security number for validation), work and credit history, driving records and any criminal history which may be in the files of any state or local criminal agency. In connection with my application for employment or continued employment at PlaneTechs (the Company), I understand that a consumer report and/or an investigative consumer report will be ordered that may include information as to my character, general reputation, mode of living, work habits, performance, and experience, along with reasons for termination of past employment. I understand that in compliance with applicable law and as directed by company policy and consistent with the job described, the Company may be requesting information from public and private sources about, but not limited to, my: workers' compensation injuries, driving record, court record, education, credentials, credit, and references. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. Medical and workers' compensation information will only be requested in compliance with the Federal Americans with Disabilities Act (ADA) and/or any other applicable state laws. Information regarding age, sex, or race will not be used as part of any employment decision. I hereby authorize this company, its corporate affiliates, its employees, its authorized agents, and representatives to verify all information contained in this form or in my application and to inquire into my character, general reputation, personal characteristics, and mode of living. Should I accept an offer of employment, I hereby authorize the obtaining of "consumer reports" and/or "investigative consumer reports" at any time after receipt of this authorization and, if I am hired, throughout my employment. I hereby release this company, its corporate affiliates, its employees, its authorized agents and representatives and all others involved in this background investigation from any liability in connection with any information they give or gather and any decisions made concerning my employment based on such information. I understand that any offer of employment I may receive is contingent upon the successful completion of the background investigation. I further understand that I have a right, under Section 606(B) of the Fair Credit Reporting Act, to make a written request to this company within a reasonable period of time for a complete and accurate disclosure of the nature and scope of the investigation requested. According to the Fair Credit Reporting Act, I am entitled to know if employment is denied because of information obtained by my prospective employer from a Consumer Reporting Agency. If so, I will be notified and given the name and address of the agency or the source that provided the information. I acknowledge that a telephonic facsimile (FAX) or photographic copy shall be as valid as the original. This release is valid for most federal, state and county agencies including the Minnesota Department of Labor. Massachusetts, Minnesota, Oklahoma, New York, Maine, Washington, New Jersey and California applicants only: if you want a free copy of the report(s) ordered, Please send a written statement to PlaneTechs. I hereby authorize, without reservation, any law enforcement agency, institution, information service bureau, school, employer, reference or insurance company contacted by PlaneTechs (the Company) or its outside agents, to furnish the information described above. I acknowledge receipt of the NOTICE 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.

Applicant Signature: pos,,,o,L a,..4.s..

Print Name: M An. flAs PAO LA C.01Q011

Date: 03 - al- 2.015 .

cynthia coroa.pdf

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