Youth/Adult Work Experience

1 NEW HIRE FORM Youth/Adult work Experience PARTICIPANT DATA Name_____ Social Security Number_____ _____ _____ (Print) Last First Middle Address _____ Street and Number City State Zip Telephone Number _____ Date of Birth _____ Please Mark ____ Male ____ Female Please Mark ___ Married ____ Single I CERTIFY THAT ALL THE INFORMATION I HAVE PROVIDED IS TRUE AND ACCURATE. _____ _____ PARTICIPANT S SIGNATURE DATE EMERGENCY CONTACTS Name_____ Relationship_____ Phone _____ (Print) (Print) Address _____ Street and Number City State Zip Alternate Contact Name _____ Phone _____ UNIQUE IS AN EQUAL OPPORTUNITY EMPLOYER PLEASE CHECK ONE OF THE FOLLOWING EQUAL ID GROUPS.

2 ___ White ___ Black or African American ___ Hispanic or Latino ___ Two or More Races ___ Asian ___ American Indian or Alaska Native ___ Native Hawaiian or Other Pacific Islander PLEASE CHECK ONE IF IT DESCRIBES YOUR VETERAN STATUS: ___ Non-Veteran ___ Veteran of Other Wars ___ Special Disabled Veteran ___ Vietnam Era Veteran (Served a minimum of 180 days between 5 August 1964 and 7 May 1975) TO BE COMPLETED BY: Eligibility / Placement Managing Contractor _____ (Please PRINT) Worksite _____ (Please PRINT) Program Title _____Hourly Pay Rate _____ Hours/Week _____ Date of Hire _____ TO BE COMPLETED BY: UniqueHR Contractor _____ Date Entered _____ Processed By _____ All information in this document isly owned by Unique Staff Leasing I, Ltd, d/b/a Unique HR and/or Unique Employment Services.

3 Use of this information, in whole or in part, without the written permission by Unique Staff Leasing I, Ltd, d/b/a Unique HR and/or Unique Employment Services is prohibited. EFFECTIVE PRIVILEGED AND CONFIDENTIAL PROPRIETARY INFORMATION and is sole All information in this document isly owned by Unique Staff Leasing I, Ltd, d/b/a Unique HR and/or Unique Employment Services. Use of this information, in whole or in part, without the written permission by Unique Staff Leasing I, Ltd, d/b/a Unique HR and/or Unique Employment Services is prohibited. EFFECTIVE PRIVILEGED AND CONFIDENTIAL PROPRIETARY INFORMATION and is sole MUTUAL AGREEMENT FOR THE RESOLUTION OF CLAIMS work Experience is provided to eligible participants for the purpose of obtaining employment basic skills training, and earnings from those jobs are Training Wages which are not subject to claims for state unemployment insurance.

4 Claims for workers compensation insurance benefits shall be resolved in accordance with applicable law: I HAVE READ, UNDERSTAND AND AGREE TO THIS AGREEMENT _____ _____ PARTICIPANT S SIGNATURE DATE PARTICIPANT ACKNOWLEDGEMENT OF RECEIPT OF HARASSMENT POLICY This will acknowledge that I have received, read and will comply with requirements of the Harassment Policy. PRINT FULL NAME _____ _____ _____ PARTICIPANT S SIGNATURE DATE MEDICAL INFORMATION AUTHORIZATION It is agreed if I am injured on any job, I will immediately notify my direct Supervisor and my WDB Contractor Representative.

5 The Contractor Representative will immediately notify the Unique Claims Manager in order to receive the proper medical attention. The injury should be reported within 24 hours. Failure to adhere to this 24-hour reporting request may result in immediate termination from the Youth/Adult work Experience Program. I agree to abide by all Unique and WDB Contractor s rules, policies and procedures, including submitting to substance abuse testing if required by Unique and/or WDB Contractor. Any person who knowingly and with intent to defraud any insurance company or other person files a claim containing any materially false information or conceals for the purpose of misleading information concerning any fact material thereof commits a fraudulent insurance act which is a crime. PRINT FULL NAME _____ _____ _____ PARTICIPANT S SIGNATURE DATE PARTICIPANT ACKNOWLEDGEMENT OF RESPONSIBILITY TO MAINTAIN A SAFE work ENVIRONMENT I agree to comply with the Safety Rules and Regulations for my assigned job and worksite.

6 Should my assignment require safety equipment, I will wear the proper safety equipment while working at my job assignment (safety equipment consists of safety glasses, hard hat, steel toe shoes, safety gloves, and protective garments). PRINT FULL NAME _____ _____ _____ PARTICIPANT S SIGNATURE DATE All information in this document isly owned by Unique Staff Leasing I, Ltd, d/b/a Unique HR and/or Unique Employment Services. Use of this information, in whole or in part, without the written permission by Unique Staff Leasing I, Ltd, d/b/a Unique HR and/or Unique Employment Services is prohibited. EFFECTIVE PRIVILEGED AND CONFIDENTIAL PROPRIETARY INFORMATION and is sole ALCOHOL AND DRUG-FREE WORKPLACE POLICY Unique and the WDB Contractor will comply with the Drug-Free Workplace Act of 1988 and with applicable state law outlawing the use of alcohol, illegal inhalants and drugs in the workplace.

7 DRUG-FREE WORKPLACE ACT OF 1988 STATEMENT The unlawful manufacture, distribution, dispensation, possession or use of a controlled substance, alcohol and illegal inhalants are prohibited by Unique and the WDB Contractor. In addition, specific action will be taken against any participant who reports to their job or who is under the influence of alcohol, illegal inhalants or drugs during the work day or who in any manner violates this policy. PARTICIPANT REQUIREMENTS 1. As a condition of participation in the Youth/Adult work Experience Program, I agree to abide by the terms of the Drug-Free Workplace Act of 1988 as well as the requirements of this policy. 2. I agree to notify the WDB Contractor Representative of any criminal drug statute conviction(s) for a violation occurring in the workplace no later than five (5) days after such conviction.

8 DEFINITIONS 1. The term drug-free workplace means a site for the performance of work at which the participants are prohibited from utilizing or being under the influence of illegal inhalants, engaging in the unlawful manufacture, distribution, dispensation, possession, or use of a controlled substance including alcohol, in accordance with the requirements of this policy. 2. The term participant means individuals engaged in the performance of work Experience activities under the Youth/Adult work Experience Program. 3. The term controlled substance means a controlled substance in schedules I through V of section 202 of the Controlled Substance Act (21 812) and further defined in regulations 21 CFR 4. The term conviction means a finding of guilt (including a plea of nolo contender) or imposition of sentence, or both by any judicial body charged with the responsibility to determine violations of the Federal or State criminal drug statutes.

9 5. The term criminal drug statute means a criminal statute involving manufacture, distribution, dispensation, use or possession of any controlled substance. SANCTIONS AND REMEDIES Any participant in violation of this policy may be terminated from the Youth/Adult work Experience Program. Nothing contained in this policy or any written verbal statements by any management or supervisory official shall be construed to alter the nature of the individual s responsibilities for participation in the Youth/Adult work Experience Program. No person has the authority to waive or vary this understanding. ALCOHOL AND DRUG TESTING POLICY All participants are required to submit to drug testing by demand. What does by demand actually imply? You could be required to submit due to reasonable suspicion, or due to random testing.

10 If you are tested and you test positive for drugs and/or alcohol, you will be counseled, and if you cannot provide medical proof from your doctor for the positive results, you may be terminated from the program. If you are injured while on the job, Unique will arrange for you to be taken to a nearby facility to receive appropriate medical treatment as provided under the Texas Workers Compensation Act. You will be required to be tested for drugs and alcohol within 24 hours of the accident. If you fail to adhere to this request, you will be terminated from the program. If you test positive for alcohol or drugs, your workers compensation benefits may be terminated or reduced, based on Texas Workers compensation Act, and you will be terminated from the program. _____ _____ PARTICIPANT S SIGNATURE DATE All information in this document isly owned by Unique Staff Leasing I, Ltd, d/b/a Unique HR and/or Unique Employment Services.