STEP THREE OF FOUR

333 South 1st Street, Ste. E
Hamilton, MT 59840
Phone: 406-363-7668
Fax: 1-800-298-0016

First name

Last Name

Phone

SAFETY AND HEALTH PROGRAM : I have read, understand and will comply with SS Staffing, Inc Safety and Health Program. I understand that violation of any of the policies outlined in the Safety and Health Program will result in immediate disciplinary action including immediate termination. The policy and procedures related in this handbook are provided as standards and guidelines but are not considered as an employee contract. Both the employee and SS Staffing, Inc reserve the right to terminate the employment relationship. SS Staffing, Inc. reserves the right to modify, expand or delete policies beyond those expressed in this handbook. I understand that I am not to use my personal vehicles, equipment or tools on any job assignment unless I have written authorization from SS Staffing, Inc. to do so. I hold SS Staffing, Inc completely harmless of any and all damages or losses if I do so without written permission of SS Staffing, Inc. I have read this handbook and understand all the rules and regulations stated therein. I agree to follow all rules stated in this handbook while employed by SS Staffing, Inc.

Safety And Healh Signature

Todays Date

STEPLADDERS AND LADDERS 1. Do not use ladders that have loose rungs, missing rubber foot pads, split or cracked rails, or are visibly damaged in any way. 2. Lock all doorways that you are blocking with the ladder and post signs that will detour traffic away from your work. 3. Read and follow the manufacturer’s instructions label affixed to the ladder if you are unsure how to use the ladder. 4. Do not use a metal ladder on a rooftop or within fifty (50) feet of electrical power lines. 5. Keep ladder rungs clean and free of grease. If wet be sure to wipe off rungs before use. Remove buildup of material such as dirt or mud. 6. Allow only one person on the ladder at a time. Always face the ladder when climbing up or down the ladder. 7. Do not use ladder as a horizontal platform. 8. When performing work from a ladder, face the ladder and do not lean backward or sideways from the ladder. 9. Do not place ladders in a passageway or doorway without posting warning signs or cones that will detour everyone away from ladder. 10. Secure ladder or stepstool in place by having someone else hold it. 11. When using a ladder or stepstool, never stand on the top two (2) rungs. 12. Do not place ladder at a blind corner without blocking foot traffic by roping off area or blocking the area. 13. Do not stand on tables, boxes, chairs, or other improvised climbing devises to reach designated high places. 14. Maintain a three- point contact by keeping both hands and one foot or both feet, and at least one hand on the ladder at all times when climbing up or down ladder. 15. Do not stand on the top of a ladder that wobbles, or that leans to the right or left of center. 16. When you are using a ladder, extend the top of the ladder at least three (3) feet above the edge of the landing. 17. Do not try to walk a ladder by rocking it. 18. Do not move a rolling ladder while someone is on it. 19. Do not carry items in your hands while climbing up or down the ladder. 20. Do not place ladder or stepstool on a barrel, boxes, loose bricks, pails, concrete blocks or any other unstable base.

Stepladders/Ladders Employee Signature

Todays Date

LIFTING AND PROPER BODY MECHANICS

RISK FACTORS FOR BACK INJURY:
1. Lifting with you back bowed out
2. Jerking or twisting
3. Obesity
4. Bending and reaching with your back bowed out
5. Loss of strength and flexibility
6. Slouched sitting
7. Lack of proper rest
8. Stressful working and living habits
9. Poor nutrition
10. Smoking

PROPER LIFTING TECHNIQUES:

Todays Date

Lifting/Proper Body Mechanics Signature

CHILD SUPPORT OBLIGATION DISCLOSURE FORM

TO ALL NEW EMPLOYEES: Section 40-5-425, Montana Code Annotated requires you complete this form for your employer. CHECK ONE OF THE FOLLOWING:

Select an option

I have a child support order, which requires automatic income withholding.

I have a child support order that I pay, and it is not to be withheld from my paycheck.

I do not have a Child Support Withholding Order.

The amount withheld for Court Ordered Support (PER MONTH) should be $

Child Support Disclosure Signature

Todays Date

TO EMPLOYER: Retain this form for three (3) years after the date of hiring or one (1) year after the date Employment terminates, whichever is later. If the employee owes a child support obligation subject to automatic withholding, begin deducting child support immediately. Retain this money until you receive an “Order to Withhold” from the Montana Department of Social and Rehabilitation Services, Child Support Enforcement Division. If an “Order to Withhold” is not received within 45 days, call the CSED regional office serving your county. Use this form for new employees only. You are prohibited from asking prospective employees to complete this form.

Drug Free Workplace

I do hereby certify that I have received and read the SS Staffing, Inc substance abuse and testing policy and have had the drug-free workplace program explained to me. I understand that if my performance indicates it is necessary, I will submit to a drug and/or alcohol test. I also understand that failure to comply with a drug and/or alcohol testing request or a positive confirmed result for the illegal use of drugs and/or alcohol may lead to discipline up to and including termination of employment and/or loss of Workers’ Compensation benefits. Pursuant to Montana Code 39-2-205 through 39-2-211

Drug Free Workplace Signature

Todays Date

Obligation of Hours

Temporary assignments are defined as intended to last only for a short period of time. If the Client would like to keep you as a potential long-term employee, you fall under a temp to hire employee and are required to complete the 480 contracted hours per assignment.

Temp to hire assignments are defined as potential long-term opportunities. You are required to remain on SS Staffing, Inc.’s payroll for a total of 480 contract hours. You must complete 480 hours before you can be placed on the Client’s payroll, but they are not obligated to bring you onto their payroll at that time. Anytime within that 480 contract hour period, the Client has the option to end that relationship as well as the employee, if either party doesn’t feel it’s a right fit for the position. You, as an SS Staffing, Inc. employee are required to give a two week notice to SS Staffing, Inc. in a temp to hire position. If you do not give and/or fulfill a 2 week notice, it may result in termination for future employment through SS Staffing, Inc.

If SS Staffing, Inc. refers you to a Client and that Client decided to offer you a position (whether it is the original position SS Staffing, Inc. referred you to or not), you will then fall under a temp-to-hire employee and will be required to fulfill 480 contracted hours. Now, if the Client would like to buy-out your contract they must contact SS Staffing, Inc. management to negotiate a buy-out-fee. If you the employee would prefer not to fulfill the 480 contract hours with SS Staffing, Inc., the employee may buy-out their contract for a fee negotiated with SS Staffing, Inc. management.

Obligation of Hours Signature

Todays Date

EMPLOYEE CONTACT INFORMATION

EMPLOYEE FULL NAME

EMPLOYEE ADDRESS

EMPLOYEE PHONE NUMBER

FIRST EMERGENCY CONTACT

EMERGENCY PHONE NUMBER ONE

WHAT IS THEIR RELATION TO YOU

SECOND EMERGENCY CONTACT

EMERGENCY PHONE NUMBER TWO

WHAT IS THEIR RELATION TO YOU

Affirmative Action Information

The Following information is optional to provide. Your voluntary cooperation is requested in order for us to comply with Federal Government record keeping, reporting and other legal requirements. Your answers are confidential and will only be used in administration of our Affirmative Action Program. This will be kept separate from your personal file and will not be used as a basis for any employment decision. Proof of race, veteran status or national origin may be required, if hired by us, to comply with Federal Government requirements.

EMPLOYEE FULL NAME

SOCIAL SECURITY NUMBER

POSITION YOU ARE APPLYING FOR

SEX

FEMALE

MALE

VETERAN STATUS

Vietnam Era Veteran

Disabled Veteran

WHAT PERCENT DISABLED

DO YOU HAVE A HANDICAP

YES

IF YES IS IT

SENSORY

MENTAL

PHYSICAL

STEP THREE OF FOUR

333 South 1st Street, Ste. E Hamilton, MT 59840 Phone: 406-363-7668 Fax: 1-800-298-0016

CHILD SUPPORT OBLIGATION DISCLOSURE FORM TO ALL NEW EMPLOYEES: Section 40-5-425, Montana Code Annotated requires you complete this form for your employer. CHECK ONE OF THE FOLLOWING:

EMPLOYEE CONTACT INFORMATION

333 South 1st Street, Ste. E
Hamilton, MT 59840
Phone: 406-363-7668
Fax: 1-800-298-0016

CHILD SUPPORT OBLIGATION DISCLOSURE FORM

TO ALL NEW EMPLOYEES: Section 40-5-425, Montana Code Annotated requires you complete this form for your employer. CHECK ONE OF THE FOLLOWING: