The Dubin Group. If Part-Time, Specify Your Available Hours By Day: Regular Full Time Regular Part Time S M T W Temporary Seasonal/On-Call H F S

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1 The Dubin Group NOTICE TO Applicants Innovative Employer Solutions is an equal opportunity employer. We are committed to providing equal employment opportunities to you and all other persons without regard to race, color, religion, sex, national origin, marital status, citizenship status, age, disability or veteran status. Anyone requiring a reasonable accommodation for the application and/or interview process should notify the Human Resource Department. Today s Date Name Social Security # Last First MI Current Address Street City State Zip County Local Tax Jurisdiction Telephone Number Years At Current Address Previous Address Position Applying For Street City State Zip Date Available To Start Work Schedule: If Part-Time, Specify Your Available Hours By Day: Regular Full Time Regular Part Time S M T W Temporary Seasonal/On-Call H F S Check All Shifts For Which You Are Available 1 st Shift 2 nd Shift 3 rd Shift Rotating Shifts Are You Available To Work Overtime? Yes No Have You Ever Been Bonded? Yes No Do You Have A Legal Right To Work In The U.S.? Yes No If Under 18, Can You Furnish A Work Permit If Required, Do You Have A Valid Drivers License? Yes No Have You Ever Worked With Us Before? Yes No If Yes, List Position / Dates / Location List Any Relatives Or Friends Working With Us Now Who Referred You For This Opening? Have You Ever Been Convicted Of A Felony? Yes No If Yes, Please Explain (This Will Not Automatically Bar You From Employment) Yes No Application for Co-Employment IES Form 4004 Rev

2 Employment: List All Employment Experience Beginning With Most Recent Employer. (Including Military History) Dates (Mo/Yr) Employer (Name, Address, Phone) Pay Rate Reason For Leaving From To Starting Ending Job Title Immediate Supervisor (Name & Title) Give Brief Description Of Job Duties: Dates (Mo/Yr) Employer (Name, Address, Phone) Pay Rate Reason For Leaving From To Starting Ending Job Title Give Brief Description Of Job Duties: Immediate Supervisor (Name & Title) Dates (Mo/Yr) Employer (Name, Address, Phone) Pay Rate Reason For Leaving From To Starting Ending Job Title Immediate Supervisor (Name & Title) Give Brief Description Of Job Duties: Additional Information Emergency Contact: Name: Day Phone: Relationship: Evening Phone: Applicant Statement I certify that the information provided by me on this application is true and complete to the best of my knowledge. I understand that any material omission or false or misleading statements can result in the termination of my employment, whenever it is discovered. I give Innovative Employer Solutions and my Worksite Employer, their agents and assigns, the right to contact and obtain information from all references, employers, educational institutions and to otherwise verify the accuracy of the information provided in this application. I hereby release from all liability IES or my Worksite Employer, their agents and assigns, for seeking, gathering, and using such information. I also release from all liability all persons, corporations or organizations for furnishing such information. Unless I am a contractual employee, I understand that I am an at-will employee and am free to resign at any time and Innovative Employer Solutions or my Worksite Employer, their agents or assigns, is free to terminate my employment at any time with or without reason or notice. This application does not constitute an agreement or contract for employment for any specified period or duration. I understand that no representative of IES or my Worksite Employer, other than an authorized officer, has the authority to make any assurances to the contrary. In consideration of the Company entertaining this application for employment, I understand that any and all disputes or claims arising from this application or subsequent employment shall be resolved pursuant to the rules and procedures of the ADR Systems of America, L.L.C. All disputes or claims shall first be submitted to mediation, and if not resolved, to final and binding arbitration pursuant to the provisions of the Federal Arbitration Act. I understand that my right to a trial by jury and appeal is waived. Applicant s Signature Date

3 Worksite Employer: Dubin Group Inc Employee Name: Address: Street, Apt, City, State, Zip Social Security Number: In Case of an Emergency, Please Contact: 1. Name: Relationship: Address: Street, Apt, City, State, Zip I authorize The Dubin Group to seek emergency treatment for me. I am allergic to the following medications: Employee Signature Date Professional References Please list the names and contact information for three (3) professional references. List only those to whom you directly reported, or with whom you have/had a direct working relationship. Name and Job Title: Company: Address: Name and Job Title: Company: Address: Name and Job Title: Company: Address:

4 The Dubin Group address: Primary phone #: Secondary Phone #: In what industries have you previously worked? When are you available? Ideal position/title: Ideal hourly requirement Minimum: Languages spoken: C heck all locations in which you are willing to work: Center City King of Prussia South Jersey Trenton/Princeton Bucks County Delaware Delaware County Northeast Philadelphia Other: C heck the level of education you have completed: High School Associate s degree Some of Bachelor s Bachelor s degree Master s or higher List recent temporary assignments and Supervisor/Department: Know of anyone looking? We pay referral fees! Please list below. Name Phone number City of residence Type of work Have you ever been convicted of a felony? Have you ever had a background check performed? I understand The Dubin Group (its clients and/or agents) may conduct a background investigation, credit report and reference check for the purposes of securing employment for my behalf. I agree to release The Dubin Group from any liability or action that may result from such investigation. Furthermore, should I participate in a video interview I understand this video, upon my verbal approval, could be sent to a Dubin Group client for the purposes of evaluation for a possible interview or to secure employment. In addition, the information I have presented/supplied is accurate to the best of my ability. The Dubin Group requires a notice of five business days to end an assignment before its completion date. Should I leave an assignment early for any reason before its completion date without giving five business days notice, I will receive minimum wage for the hours worked during the pay period. I acknowledge that should I leave an assignment on my own free will any time during the first day of an assignment, walk out during the first day or fail to show up on the second day, I will receive minimum wage for the hours worked during the first day of the assignment, and will receive my paycheck within 30 days. In addition, I understand under the terms of agreement between The Dubin Group and their clients, I cannot accept a position in any capacity at a client for a period of six (6) months after I leave an assignment. This means I can not be an independent contractor, a temporary or a full-time employee in any position. Should I work with a client during this time, both the client and myself will be liable for a conversion/placement fee and any legal fees associated with collection of such fee. The Dubin Group shares in a co-employment relationship with Innovative Employer Solutions (IES). What that means is that The Dubin Group is your worksite employer maintaining direction and control of the worksite on a daily basis. IES is your administrative employer, providing administrative services like payroll and fax filing. For unemployment or tax purposes, you should list The Dubin Group/IES as your employer. I am aware that if I am placed on assignment and I should be ended or resign from that assignment and become available for work again, I must report to The Dubin Group that I am available for new employment once every month. If I fail to call and report my availability, my actions will be considered a voluntary quit from The Dubin Group. Signature Date

5 I AM WILLING TO WORK (check all that apply): 1 DAY ASSIGNMENT SHORT TERM (1 MONTH OR LESS) LONG TERM (1 MONTH OR MORE) PART TIME ADMINISTRATIVE SKILLS (please check what you have ON THE JOB experience with): DICTAPHONE DICTATION MAIL MERGE SHORTHAND SWITCHBOARD TRANSCRIPTION REAL ESTATE LICENSE TRAVEL ARRANGEMENTS ADMINISTRATIVE SOFTWARE (please check what you have experience with an knowledge of): ACT ADOBE AMI PRO ELITE FOXPRO GOLDMINE GREAT PLAINS DYNAMICS HTML HRIS IDX JURIS LEXIS NEXIS LOTUS LOTUS FREELANCE LOTUS NOTES MAS 90 MS ACCESS MS EXCEL MS WORD MS POWERPOINT MS PROJECT MS PUBLISHER MS OUTLOOK OTHER DATABASE PEOPLESOFT PAGEMAKER PHOTOSHOP QUARK EXPRESS SAP VISIO WESTLAW WORDPERFECT WPM ACCOUNTING SKILLS (please check what you have ON THE JOB experience with): ACCOUNT RECONCILIATION AP AR ANALYSIS AUDIT BANK RECONCILIATION BILLING BOOKKEEPING BUDGETING CASH APPLICATION CASH MANAGEMENT COLLECTIONS CONSOLIDATION COST ACCOUNTING FEDERAL TAX FINANCIAL ANALYSIS FINANCIAL RECONCILIATION FINANCIAL REPORTING FINANCIAL STATEMENT PREPARATION FIXED INCOME SECURITY FIXED ASSETS FORECASTING GAAP GENERAL LEDGER INTERNATIONAL TAX INVENTORY JOB COSTING JOUNRAL ENTRIES LEGAL BILLING MEDICAL BILLING MERGERS & ACQUISITIONS MODELING MONTH END CLOSE MUTUAL FUND ACCOUNTING NONPROFIT ACCOUNTING PAYROLL PAYROLL TAX PURCHASING SEC REPORTING STANDARD COST STATE AND LOCAL TAX TREASURY

6 ACCOUNTING SOFTWARE (please check what you have ON THE JOB experience with): ACCPAC ADP AMSI ARGUS AS400 AXIUM BEST FIXED ASSET CERIDIAN ELITE FAS109 FAS FIXED ASSET FAST TAX FOXPRO GREAT PLAINS HRIS HYPERION JD EDWARDS KRONOS LAWSON MACOLA MAPIC MAS90 MAS200 MRI MSA MYOB ORACLE OTHER PAYROLL SYSTEM PAYCHECK PEACHTREE PEOPLESOFT PLATINUM QUICKBOOKS QUICKEN REAL ESTATE SOFTWARE REAL WORLD RENT ROLL SAP SIEBEL SKYLINE SOLOMON SQL TIMBERLINE TURBO TAX VERITAS YARDI MAY WE CONTACT YOU THROUGH (please check if you would like us to contact you this way for networking purposes): TEXT MESSAGE LINKED IN FACEBOOK TWITTER OTHER