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Employment Application
Date_______________
Applications are considered for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, or in the
presence of a non-related medical condition or handicap.
Name__________________________________________ Social Security #_______________________
Address________________________________________________Phone #_______________________
City_____________________________State__________Zip____________DOB____________________
Email address_________________________________________________________________________
Are you a citizen of the United States of America?
[ ] Yes [ ] No
Are you a veteran of the U.S. Military service?
[ ] Yes [ ] No
Have you been convicted of a felony?
[ ] Yes [ ] NO. If yes, please explain___________
Position applied for______________________________________Pay Requirement______________
Date Available_________________ [ ] Full time [ ] Part time [ ] Temporary [ ] Seasonal
EMPLOYMENT EXPERIENCE; Start with your present job or last job. Include military assignments and other volunteer activities. Exclude
organizational names which indicate race, color, religion, sex, or national origin.
Employer 1__________________________________________________________________________
Address___________________________________City________________State_______Zip__________
Phone #________________Supervisors’ Name_______________________________________________
Job Title______________________Reason for leaving_________________________________________
Dates of Employment: From_________To__________ Salary or Hourly rate________________________
Employer 2__________________________________________________________________________
Address___________________________________City________________State_____Zip____________
Phone #________________Supervisors’ Name______________________________________________
Job Title______________________Reason for leaving_________________________________________
Dates of Employment: From_________To__________ Salary or Hourly rate________________________
Education
Schools/Colleges Attended:
____________________________________________________
# Years Year Grad. Degree
_______ _______ _________
____________________________________________________
_______ _______ _________
Emergency Contact __________________________________________________________________
Name
Phone Number
I CERTIFY that answers given herein are true and complete to the best of my knowledge. I authorize investigations of all statements contained
in this application for employment as may be necessary in arriving at an employment decision. I understand that this application is not intended
to be a contract of employment. In the event of employment, I understand that false or misleading information given on my application or
interview may result in termination.
Signature___________________________________________________Date______________________
EMPLOYEE SAFETY ACKNOWLEDGEMENT FORM
CODE OF SAFE PRACTICES – “SAFETY IS NO ACCIDENT”
I agree to conform to all practices, safety rules, and regulations relating to safe work performance.
I understand that my failure to follow these safety procedures will result in disciplinary action up to and including discharge.
I further understand that:
1. It is my responsibility to report all unsafe conditions or violations of the Code of Safe Practices to my supervisor or
other management personnel in order to minimize the potential of injury to my fellow workers.
2. I am encouraged to inform my immediate superior of any hazards on the job without fear or reprisal and, should my
concerns go unnoticed or be retaliated against, that I am encouraged to contact the Safety Coordinator or
management by phone or mail.
3. The use, possession, sale or contact of illegal drugs or alcohol on facility/company property is strictly
prohibited. If injured on the job, you may be required to submit to a drug and alcohol test. If you refuse to take
the test, you may affect the eligibility of workers’ compensation benefits. If results of such tests prove positive, you
may not only forfeit workers’ compensation benefits, but you may also be released from employment immediately.
4. I have read the Devau Human Resouces’ safety rules and regulations contained in Devau Human Resources Injury
Illness, Prevention Program, & Comprehensive Workplace Safety Manual found online (www.devauhr.com). I
acknowledge that a hardcopy is available at my request. I understand these safety rules and I agree to follow them.
When in doubt concerning safe job performance, I will speak to my immediate supervisor. I understand that if I have
any questions and/or need clarification for items addressed in the manual, it is my sole responsibility to contact Devau
Human Resources for discussion.
5. I acknowledge that per Devau Human Resources policy, upon learning of a work-related injury or illness, Devau
Human Resources must conduct a preliminary investigation and gather witness statements as soon as possible. I
pledge to fully cooperate in any workplace-injury investigation in the event that I am injured in the workplace for
the purpose of improving employee safety training needs, identifying hazards, recommending corrective actions,
and helping Devau Human Resouces and the insurer identify workers’ compensation fraud.
6. Devau Human Resources sincerely hopes that you are never injured. However, if while on the job, an injury does
occur, it is our desire for you to have well-organized medical treatment and to receive benefits. In order for this
to happen, you must be fully aware that an injury report form and drug test must be completed within 24
hours of your injury. Failure to do so could affect the execution of your benefits.
_____________________________________
Signature of Employee
_____________________________________
PRINTED NAME of Employee
_______________
Date
Arizona Form
A-4
2015
Employee’s Arizona Withholding Election
Type or print your Full Name
Your Social Security Number
Home Address – number and street or rural route
City or Town
State
ZIP Code
Choose either box 1 or box 2:
1 Withhold from gross taxable wages at the percentage checked (check only one percentage):
0.8%
1.3%
1.8%
2.7%
3.6%
4.2%
Check this box and enter an extra amount to be withheld from each paycheck ................
5.1%
$
2 I elect an Arizona withholding percentage of zero, and I certify that I expect to have
no Arizona tax liability for the current taxable year.
Print
I certify that I have made the election marked above.
SIGNATURE
DATE
Employee’s Instructions
Arizona law requires your employer to withhold Arizona income
tax from your wages for work done in Arizona. This amount
is applied to your Arizona income tax due when you file your
tax return. The amount withheld is a percentage of your gross
taxable wages of every paycheck. You may also have your
employer withhold an extra amount from each paycheck.
Complete this form to select a percentage and any extra
amount to be withheld from each paycheck.
What are my “Gross Taxable Wages”?
For withholding purposes, your “gross taxable wages” are the
wages that will generally be in box 1 of your federal Form W-2.
It is your gross wages less any pretax deductions, such as your
share of health insurance premiums.
New Employees
Complete this form in the first five days of employment to select
an Arizona withholding percentage. You may also have your
employer withhold an extra amount from each paycheck. If you
do not file this form, the department requires your employer to
withhold 2.7% of your gross taxable wages.
Current Employees
If you want to change the current amount withheld, you must
file this form to change the Arizona withholding percentage or
change the extra amount withheld.
What Should I do With Form A-4?
Give your completed Form A-4 to your employer.
ADOR 10121 (14)
Electing a Withholding Percentage of Zero
You may elect an Arizona withholding percentage of zero
if you expect to have no Arizona income tax liability for the
current year. Arizona tax liability is gross tax liability less any
tax credits, such as the family tax credit, school tax credits, or
credits for taxes paid to other states. If you make this election,
your employer will not withhold Arizona income tax from your
wages for payroll periods beginning after the date you file
the form. Zero withholding does not relieve you from paying
Arizona income taxes that might be due at the time you file
your Arizona income tax return. If you have an Arizona tax
liability when you file your return or if at any time during the
current year conditions change so that you expect to have a tax
liability, you should promptly file a new Form A-4 and choose a
percentage that applies to you.
Voluntary Withholding Election by Certain
Nonresident Employees
Compensation earned by nonresidents while physically working
in Arizona for temporary periods is subject to Arizona income
tax. However, under Arizona law, compensation paid to certain
nonresident employees is not subject to Arizona income tax
withholding. These nonresident employees need to review
their situations and determine whether they should elect to
have Arizona income taxes withheld from their Arizona source
compensation. Nonresident employees may request that their
employer withhold Arizona income taxes by completing this
form to elect Arizona income tax withholding.
AUTHORIZATION AGREEMENT
FOR DIRECT DEPOSITS
I hereby authorize Devau Human Resources, hereinafter called COMPANY, to initiate credit
entries and to initiate, if necessary, debit entries for any credit entries made in error to my account
listed below and the financial institution named below, hereinafter called INSTITUTION, to credit or
debit the same to such account.
Checking
Savings
________________________________
FINANCIAL INSTITUTION NAME
________________
CITY
_____________________________________
ROUTING NUMBER
(Select one)
__________
STATE
___________
ZIP CODE
________________________________________
ACCOUNT NUMBER
PLEASE ATTACH A VOIDED CHECK
This authority is to remain in full force and effect until COMPANY has received notification from me of
its termination in such time and in such manner as to allow COMPANY and INSTITUTION a
reasonable opportunity to act on it.
________________________________________
EMPLOYEE NAME (PLEASE PRINT)
_________________________
DATE
_____________________________________
NAME ON ACCOUNT (If different)
_______________________________________________
SIGNATURE
Devau Human Resources – 720 E. North Lane, Suite #1 Phoenix, AZ 85020 – Fax: 602-314-5033