New Hire Packet - Derrick West

Employee : Derrick West

Start Date: 8/13/2023
Department: Warehouse
Office: Houston, Tx
Manager: Malaney Shrum
Coordinator: Valerie Garcia

1. Table of Contents.......................................1
2. Tearsheet...............................................2
3. New Hire Packet Task Summary............................3
4. Personal Data Sheet.....................................4
5. Direct Deposit Form.....................................6
6. EEO Form................................................8
7. Federal W4..............................................9
8. Form I-9...............................................16
9. VEVRAA Post Offer......................................22
10. Voluntary Self-ID of Disability.......................23
11. Background Check Authorization........................25
12. Employee Handbook.....................................29
13. Handbook Acknowledgement..............................30
14. Photo Release Form....................................31
15. Benefit Enrollment Guide..............................32
16. Wage Deduction Authorization Form (ENG)...............33
17. Benefits Acknowledgement Page.........................34
18. Photo Social Media Release Form (ENG).................35
New Hire Tasks

1. Welcome Completed By Derrick West on 8/10/2023

2. Personal Data Sheet Completed By Derrick West on 8/10/2023

Approved By Valerie Garcia on 8/10/2023

3. Direct Deposit Form Completed By Derrick West on 8/10/2023

Approved By Valerie Garcia on 8/10/2023

4. EEO Form Completed By Derrick West on 8/10/2023

Approved By Valerie Garcia on 8/10/2023

5. Federal W4 Completed By Derrick West on 8/10/2023

Approved By Valerie Garcia on 8/10/2023

6. Form I-9 Completed By Derrick West on 8/10/2023

Approved By Raquel Campos on 8/14/2023

7. VEVRAA Post Offer Completed By Derrick West on 8/10/2023

Approved By Valerie Garcia on 8/10/2023

8. Voluntary Self-ID of Disability Completed By Derrick West on 8/10/2023

Approved By Valerie Garcia on 8/10/2023

9. Background Check Authorization Completed By Derrick West on 8/10/2023

Approved By Valerie Garcia on 8/10/2023

10. Employee Handbook Completed By Derrick West on 8/10/2023

11. Handbook Acknowledgement Completed By Derrick West on 8/10/2023

Approved By Valerie Garcia on 8/10/2023

12. Photo Release Form Completed By Derrick West on 8/10/2023

Approved By Valerie Garcia on 8/10/2023

13. Benefit Enrollment Guide Completed By Derrick West on 8/10/2023

14. Wage Deduction Authorization Form (ENG) Completed By Derrick West on 8/10/2023

15. Benefits Acknowledgement Page Completed By Derrick West on 8/10/2023

16. Photo Social Media Release Form (ENG) Completed By Derrick West on 8/10/2023
Personal Data Form

LEGAL FIRST NAME LEGAL MIDDLE NAME LEGAL LAST NAME PREFERRED NAME SSN (XXX-XX-XXXX)
Derrick West 450-92-5860

DATE OF BIRTH (MM/DD/YYYY) STREET ADDRESS ADDRESS 2 ADDRESS 3

01/02/1982 401 South Bender Apt1605

CITY STATE ZIP COUNTY COUNTRY

Humble Texas 77338 United States

EMAIL ADDRESS PRIMARY PHONE GENDER MARITAL STATUS MARITAL STATUS

EFFECTIVE DATE (IF SINGLE
bettathanbefoe@gmail.com 409-797-9541 [X] Male Single INPUT DATE OF BIRTH)
[ ] Female MM/DD/YYYY

[ ] Non-Binary 01/02/1982

Emergency Contact
FULL NAME RELATIONSHIP EMAIL (IF NO EMAIL ADDRESS, PHONE AREA CODE (INPUT 3 PHONE DIAL NUMBER (INPUT 7
ENTER N/A) DIGITS) DIGITS XXX-XXXX)
Precious Moore Parent
Na 832 965-5434

ADDRESS LINE 1 ADDRESS LINE 2 ADDRESS LINE 3 CITY STATE

Texas

COUNTRY ZIPCODE
United States

Signature
SIGNED DATE (MM/DD/YYYY)
Derrick West 01/02/1982

ADP Payroll Information

ADP PAY GRADE CODE ADP COMPANY CODE ADP WORKER CATEGORY ADP BENEFITS ELIGIBILITY FLSA
CODE CLASS CODE
PMJ N/A

ADP Pay Amount (Only fill out one of the options below: Daily Rate, Hourly Rate or Per-Pay-Period Rate)
DAILY RATE HOURLY RATE PER-PAY-PERIOD RATE

ADP Pay Frequency

PAY FREQUENCY
--Select--
Approval Signature
SIGNED DATE
Valeie Garcia 08/10/2023
ADP EMPLOYEE DIRECT DEPOSIT ENROLLMENT FORM
To sign up for Full Service Direct Deposit, complete this enrollment form.

To enroll in ADP Full Service Direct Deposit, simply fill out this form. If depositing to a savings account, ask your bank to
give you the Routing/Transit Number for your account. It isn't always the same as the number on a savings deposit slip.
This will help ensure that you are paid correctly.

Below is a sample check MICR line, detailing where the information necessary to complete this form can be found.

Important! Please read and sign before completing and submitting.

I hereby authorize Employer, either directly or through its payroll service provider, to deposit any amounts owed me, by
initiating credit entries to my account at the financial institution (hereinafter "Bank") indicated on this form. Further, I
authorize Bank to accept and to credit any credit entries indicated by Employer, either directly or through its payroll service
provider, to my account. In the event that Employer deposits funds erroneously into my account, I authorize Employer,
either directly or through its payroll service provider, 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 Employer and Bank have received
written notice from me of its termination in such time and in such manner as to afford Employer and Bank reasonable
opportunity to act on it.

EMPLOYEE FIRST NAME EMPLOYEE LAST NAME SOCIAL SECURITY NUMBER

Derrick West 450-92-5860

Account Information
Account #1
ACCOUNT TYPE ROUTING NUMBER ACCOUNT NUMBER
Checking Account 091302966 304150903298

WHAT AMOUNT DO YOU WANT TO DEPOSIT INTO IF PERCENT AMOUNT, WHAT PERCENTAGE OF IF FIXED AMOUNT, WHAT AMOUNT OF YOUR
THIS ACCOUNT? YOUR PAYCHECK DO YOU WANT TO DEPOSIT INTO PAYCHECK DO YOU WANT TO DEPOSIT INTO THIS
THIS ACCOUNT? ACCOUNT?
Percent Amount
50

Account #2
ACCOUNT TYPE ROUTING NUMBER ACCOUNT NUMBER
Checking Account 111000025 488117374102
 WHAT AMOUNT DO YOU WANT TO DEPOSIT INTO IF PERCENT AMOUNT, WHAT PERCENTAGE OF IF FIXED AMOUNT, WHAT AMOUNT OF YOUR
THIS ACCOUNT? YOUR PAYCHECK DO YOU WANT TO DEPOSIT INTO PAYCHECK DO YOU WANT TO DEPOSIT INTO THIS
THIS ACCOUNT? ACCOUNT?
Remaining Amount

Account #3
ACCOUNT TYPE ROUTING NUMBER ACCOUNT NUMBER
N/A

WHAT AMOUNT DO YOU WANT TO DEPOSIT INTO IF PERCENT AMOUNT, WHAT PERCENTAGE OF IF FIXED AMOUNT, WHAT AMOUNT OF YOUR
THIS ACCOUNT? YOUR PAYCHECK DO YOU WANT TO DEPOSIT INTO PAYCHECK DO YOU WANT TO DEPOSIT INTO THIS
THIS ACCOUNT? ACCOUNT?
--select--

Account #4
ACCOUNT TYPE ROUTING NUMBER ACCOUNT NUMBER
N/A

WHAT AMOUNT DO YOU WANT TO DEPOSIT INTO IF PERCENT AMOUNT, WHAT PERCENTAGE OF IF FIXED AMOUNT, WHAT AMOUNT OF YOUR
THIS ACCOUNT? YOUR PAYCHECK DO YOU WANT TO DEPOSIT INTO PAYCHECK DO YOU WANT TO DEPOSIT INTO THIS
THIS ACCOUNT? ACCOUNT?
--select--

Employee Signature
SIGNED DATE
Derrick West 08/10/2023

ADP Deduction Code

Please input the ADP deduction code for each account indicated above.
For instructions on how to view your ADP deduction codes, please view a guide here

ACCOUNT #1 DEDUCTION CODE ACCOUNT #2 DEDUCTION CODE ACCOUNT #3 DEDUCTION CODE ACCOUNT #4 DEDUCTION CODE
CK1 CK2

Approval Signature
SIGNED DATE (MM/DD/YYYY)
Valerie Garcia 08/10/2023
 Voluntary Self-Identification Form

FIRST NAME LAST NAME

Derrick West

ETHNICITY

[ ] I choose not to self-identify at this time

[ ] Hispanic / Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish
culture or origin regardless of race.)

Non-Hispanic / Latino

[ ] Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian
Subcontinent, including for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine
Islands, Thailand and Vietnam.)

[ ] American Indian, Alaskan Native (A person having origins in any of the original peoples of North and
South America (including Central America), and who maintain tribal affiliation or community attachment.)

[X] Black or African American (A person having origins in any of the black racial groups of Africa.)

[ ] Native Hawaiian / Other Pacific Islander (A person having origins in any of the peoples of Hawaii, Guam,
Samoa, or other Pacific Islands.)

[ ] White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.)

[ ] Non-Hispanic / Latino - Two or More Races (All persons who identify with more than one of the above races,
excluding those who identify themselves as Hispanic or Latino.)

GENDER
Male

Signature
SIGNED DATE
Derrick West 08/10/2023
 OMB No. 1545-0074
Form W-4
Department of the Treasury Internal Revenue Service
2023

Employee's Withholding Certificate

Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.

Give Form W-4 to your employer.

Your withholding is subject to review by the IRS.

Step 1: Enter Personal Information

(A) FIRST NAME MIDDLE INITIAL LAST NAME (B) SOCIAL SECURITY NUMBER

Derrick West 450-92-5860

> Does your name match the name on your social security card? If not, to ensure you get credit for your earnings, contact SSA at 800-772-1213 or go to www.ssa.gov.

ADDRESS

401 South Bender

CITY OR TOWN STATE ZIP CODE

Humble Texas 77338

(C)

[ ] Single or Married filing separately

[ ] Married filing jointly or Qualifying surviving spouse

[X] Head of household (Check only if you're unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)

Complete Steps 2-4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can claim exemption from

withholding, other details, and privacy.

Step 2: Multiple Jobs or Spouse Works

Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse also works. The correct amount of withholding

depends on income earned from all of these jobs.

Do only one of the following.

(a) Reserved for future use.

(b) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below; or

(c) If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option is generally more accurate than (b)

if pay at the lower paying job is more than half of the pay at the higher paying job. Otherwise, (b) is more accurate . . . . . [ ]

Tip: If you have self-employment income, see page 2.

Complete Steps 3-4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you

complete Steps 3-4(b) on the Form W-4 for the highest paying job.)
Step 3: Claim Dependents and Other Credits

If your total income will be $200,000 or less ($400,000 or less if married filing jointly):

Multiply the number of qualifying children under age 17 by $2,000 . . . . . $

Multiply the number of other dependents by $500 . . . . . $

Add the amounts above for qualifying children and other dependents. You may add to this the amount of any other credits. Enter the total here . . . . . $

Step 4 (optional): Other Adjustments

(a) Other income (not from jobs). If you want tax withheld for other income you expect this year that won't have withholding, enter the amount of other

income here.
4(A)
This may include interest, dividends, and retirement income . . . . . $

(b) Deductions. If you expect to claim deductions other than the standard deduction and want to reduce your withholding,
4(B)
use the Deductions Worksheet on page 3 and enter the result here . . . . . $

4(C)
(c) Extra withholding. Enter any additional tax you want withheld each pay period . . . . . $

Write "Exempt" here if you had no federal income tax liability in 2022 and you expect to have no federal income tax liability in 2023:

Step 5: Sign Here

Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.

EMPLOYEE'S SIGNATURE (THIS FORM IS NOT VALID UNLESS YOU SIGN IT.) DATE

Derrick West 08/10/2023

Employers Only

EMPLOYER'S NAME EMPLOYER'S ADDRESS FIRST DATE OF EMPLOYMENT EMPLOYER IDENTIFICATION NUMBER (EIN)

Approval Signature

SIGNED DATE

Valerie Garcia 08/10/2023

General Instructions

Section references are to the Internal Revenue Code.

Future Developments
For the latest information about developments related to Form W-4, such as legislation enacted after it was published, go to www.irs.gov/FormW4.

Purpose of Form
Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. If too little is withheld, you will generally owe tax

when you file your tax return and may owe a penalty. If too much is withheld, you will generally be due a refund. Complete a new Form W-4 when changes to
your personal or financial situation would change the entries on the form. For more information on withholding and when you must furnish a new Form W-4,

see Pub. 505, Tax Withholding and Estimated Tax.

Exemption from withholding. You may claim exemption from withholding for 2023 if you meet both of the following conditions: you had no federal income
tax liability in 2022 and you expect to have no federal income tax liability in 2023. You had no federal income tax liability in 2022 if (1) your total tax on line

24 on your 2022 Form 1040 or 1040-SR is zero (or less than the sum of lines 27, 28, and 29), or (2) you were not required to file a return because your income
was below the filing threshold for your correct filing status. If you claim exemption, you will have no income tax withheld from your paycheck and may owe

taxes and penalties when you file your 2023 tax return. To claim exemption from withholding, certify that you meet both of the conditions above by writing
“Exempt” on Form W-4 in the space below Step 4(c). Then, complete Steps 1(a), 1(b), and 5. Do not complete any other steps. You will need to submit a new

Form W-4 by February 15, 2024.

Your Privacy

If you have concerns with Step 2(c), you may choose Step 2(b); if you have concerns with Step 4(a), you may enter an additional amount you want withheld
per pay period in Step 4(c).

Self-employment. Generally, you will owe both income and self-employment taxes on any self-employment income you receive separate from the wages you

receive as an employee. If you want to pay income and self-employment taxes through withholding from your wages, you should enter the self-employment
income on Step 4(a). Then compute your self-employment tax, divide that tax by the number of pay periods remaining in the year, and include that resulting

amount per pay period on Step 4(c). You can also add half of the annual amount of self-employment tax to Step 4(b) as a deduction. To calculate self-
employment tax, you generally multiply the self-employment income by 14.13% (this rate is a quick way to figure your self-employment tax and equals the

sum of the 12.4% social security tax and the 2.9% Medicare tax multiplied by 0.9235). See Pub. 505 for more information, especially if the sum of self-
employment income multiplied by 0.9235 and wages exceeds $160,200 for a given individual.

Nonresident alien. If you're a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.

Specific Instructions

Step 1(c) Check your anticipated filing status. This will determine the standard deduction and tax rates used to compute your withholding.

Step 2. Use this step if you (1) have more than one job at the same time, or (2) are married filing jointly and you and your spouse both work.
If you (and your spouse) have a total of only two jobs, you may check the box in option (c). The box must also be checked on the Form W-4 for the other job.
If the box is checked, the standard deduction and tax brackets will be cut in half for each job to calculate withholding. This option is roughly accurate for jobs
with similar pay; otherwise, more tax than necessary may be withheld, and this extra amount will be larger the greater the difference in pay is between the two

jobs.

Multiple jobs. Complete Steps 3 through 4(b) on only one Form W-4. Withholding will be most accurate if you do this on the Form W-4 for the highest paying

job.

Step 3. This step provides instructions for determining the amount of the child tax credit and the credit for other dependents that you may be able to claim
when you file your tax return. To qualify for the child tax credit, the child must be under age 17 as of December 31, must be your dependent who generally
lives with you for more than half the year, and must have the required social security number. You may be able to claim a credit for other dependents for
whom a child tax credit can't be claimed, such as an older child or a qualifying relative. For additional eligibility requirements for these credits, see Pub. 501,

Dependents, Standard Deduction, and Filing Information. You can also include other tax credits for which you are eligible in this step, such as the foreign
tax credit and the education tax credits. To do so, add an estimate of the amount for the year to your credits for dependents and enter the total amount in Step
3. Including these credits will increase your paycheck and reduce the amount of any refund you may receive when you file your tax return.

Step 4 (optional).
Step 4(a). Enter in this step the total of your other estimated income for the year, if any. You shouldn't include income from any jobs or self-employment. If
you complete Step 4(a), you likely won't have to make estimated tax payments for that income. If you prefer to pay estimated tax rather than having tax on

other income withheld from your paycheck, see Form 1040-ES, Estimated Tax for Individuals.
Step 4(b). Enter in this step the amount from the Deductions Worksheet, line 5, if you expect to claim deductions other than the basic standard deduction on
your 2023 tax return and want to reduce your withholding to account for these deductions. This includes both itemized deductions and other deductions such
as for student loan interest and IRAs.

Step 4(c). Enter in this step any additional tax you want withheld from your pay each pay period, including any amounts from the Multiple Jobs Worksheet,
line 4. Entering an amount here will reduce your paycheck and will either increase your refund or reduce any amount of tax that you owe.

Step 2(b)-Multiple Jobs Worksheet (Keep for your records.)

If you choose the option in Step 2(b) on Form W-4, complete this worksheet (which calculates the total extra tax for all jobs) on only ONE Form W-4.

Withholding will be most accurate if you complete the worksheet and enter the result on the Form W-4 for the highest paying job. To be accurate, submit a
new Form W-4 for all other jobs if you have not updated your withholding since 2019.

Note: If more than one job has annual wages of more than $120,000 or there are more than three jobs, see Pub. 505 for additional tables.

1. Two jobs. If you have two jobs or you're married filing jointly and you and your spouse each have one job, find the amount from the appropriate table
on page 4. Using the "Higher Paying Job" row and the "Lower Paying Job" column, find the value at the intersection of the two household salaries and
1
enter that value on line 1. Then, skip to line 3 . . . . . $

2. Three jobs. If you and/or your spouse have three jobs at the same time, complete lines 2a, 2b, and 2c below. Otherwise, skip to line 3.
a. Find the amount from the appropriate table on page 4 using the annual wages from the highest paying job in the "Higher Paying Job" row and the

annual wages for your next highest paying job in the "Lower Paying Job" column. Find the value at the intersection of the two household salaries
2A
and enter that value on line 2a . . . . . $

b. Add the annual wages of the two highest paying jobs from line 2a together and use the total as the wages in the "Higher Paying Job" row and use
the annual wages for your third job in the "Lower Paying Job" column to find the amount from the appropriate table on page 4 and enter this
 2B
amount on line 2b . . . . . $
2C
c. Add the amounts from lines 2a and 2b and enter the result on line 2c . . . . . $

3. Enter the number of pay periods per year for the highest paying job. For example, if that job pays weekly, enter 52;
3
if it pays every other week, enter 26; if it pays monthly, enter 12, etc. . . . . .

4. Divide the annual amount on line 1 or line 2c by the number of pay periods on line 3. Enter this amount here and in Step 4(c) of Form W-4 for the
4
highest paying job (along with any other additional amount you want withheld) . . . . . $

Step 4(b)-Deductions Worksheet (Keep for your records.)

1. Enter an estimate of your 2023 itemized deductions (from Schedule A (Form 1040)). Such deductions may include qualifying home mortgage interest,
1
charitable contributions, state and local taxes (up to $10,000), and medical expenses in excess of 7.5% of your income . . . . . $

2. Enter:
$27,700 if you're married filing jointly or qualifying surviving spouse

$20,800 if you're head of household

$13,850 if you're single or married filing separately
2
$

3. If line 1 is greater than line 2, subtract line 2 from line 1 and enter the result here. If line 2 is greater than line 1, enter "-0-" . . . . . $
3

4. Enter an estimate of your student loan interest, deductible IRA contributions, and certain other adjustments (from Part II of Schedule 1 (Form 1040)).
4
See Pub. 505 for more information . . . . . $
5
5. Add lines 3 and 4. Enter the result here and in Step 4(b) of Form W-4 . . . . . $

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(f)(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 will result in your being treated as a single person with no other entries on the form; providing fraudulent information may subject you to penalties. Routine uses of this
information include giving it to the Department of Justice for civil and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwealths and territories 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
return.
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.
Form W-4 (2023)
 Instructions

Employment Eligibility USCIS

Form I-9
Veri cation OMB No. 1615-0047
Department of Homeland Security
Expires 10/31/2022
U.S. Citizenship and Immigration Services

>START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or
electronically, during completion of this form. Employers are liable for errors in the completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which
document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ 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 I-9 no later than the
rst day of employment, but not before accepting a job o er.)
LAST NAME (FAMILY NAME) FIRST NAME (GIVEN NAME) MIDDLE INITIAL OTHER LAST NAMES USED (IF ANY)
West Derrick J Na

ADDRESS (STREET NUMBER AND NAME) APT. NUMBER CITY OR TOWN STATE ZIP
401 South Bender 1605 Humble TX 77338

DATE OF BIRTH (MM/DD/YYYY) U.S. SOCIAL SECURITY NUMBER EMPLOYEE'S E-MAIL ADDRESS EMPLOYEE'S TELEPHONE NUMBER
01/02/1982 450-93-5860 bettathanbefoe@gmail.com 409-797-9541

I am aware that federal law provides for imprisonment and/or nes 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 boxes):

[X] 1. A citizen of the United States

[ ] 2. A noncitizen national of the United States (See instructions)

[ ] 3 A lawful permanent resident (ALIEN REGISTRATION NUMBER/USCIS NUMBER):

N/A

[ ] 4. An alien authorized to work UNTIL(EXPIRATION DATE, IF APPLICABLE, MM/DD/YYYY):

SOME ALIENS MAY WRITE "N/A" IN THE EXPIRATION DATE FIELD. (SEE INSTRUCTIONS)
N/A

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration
Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number
1. ALIEN REGISTRATION NUMBER/USCIS NUMBER:
N/A

OR

2: FORM I-94 ADMISSION NUMBER:

N/A

OR

3: FOREIGN PASSPORT NUMBER:

N/A
 COUNTRY OF ISSUANCE:

SIGNATURE OF EMPLOYEE TODAY'S DATE (MM/DD/YYYY)

Derrick West 08/10/2023

Preparer and/or Translator Certi cation (check one):

[X] I did not use a preparer or translator. [ ] A preparer(s) and/or translator(s) assisted the employee in completing Section 1.

(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)

Employer Completes Next Page

 Section 2. Employer or Authorized Representative Review and Veri cation
(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's rst day of
employment. You must physically examine one document from List A OR a combination of one document from List B and one
document from List C as listed on the "Lists of Acceptable Documents.")

Employee Info from LAST NAME (FAMILY NAME) FIRST NAME (GIVEN NAME) M.I. CITIZENSHIP/IMMIGRATION STATUS
Section 1 West Derrick J 1

[ ] List A - Identity and Employment [X] List B - Identity List C - Employment Authorization
Authorization
DOCUMENT TITLE: DOCUMENT TITLE: DOCUMENT TITLE:
N/A ID card issued by state/territory Social Security Card (Unrestricted)

ISSUING AUTHORITY: ISSUING AUTHORITY: ISSUING AUTHORITY:

N/A Texas Dept. of Public Safety Social Security Admin

DOCUMENT NUMBER: DOCUMENT NUMBER: DOCUMENT NUMBER:

N/A 19131995 450-93-5860

EXPIRATION DATE (IF ANY)(MM/DD/YYYY): EXPIRATION DATE (IF ANY)(MM/DD/YYYY): EXPIRATION DATE (IF ANY)(MM/DD/YYYY):
N/A 01/02/2025 N/A

DOCUMENT TITLE:
N/A

ISSUING AUTHORITY:
N/A

DOCUMENT NUMBER:
N/A

EXPIRATION DATE (IF ANY)(MM/DD/YYYY):

N/A

DOCUMENT TITLE:
N/A

ISSUING AUTHORITY:
N/A

DOCUMENT NUMBER:
N/A

EXPIRATION DATE (IF ANY)(MM/DD/YYYY):

N/A

ADDITIONAL INFORMATION

Certi cation: 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 rst day of employment THE EMPLOYEE'S FIRST DAY OF EMPLOYMENT (MM/DD/YYYY):
(mm/dd/yyyy): 08/13/2023

SIGNATURE OF EMPLOYER OR AUTHORIZED REPRESENTATIVE TODAY'S DATE (MM/DD/YYYY)

Raquel Campos 08/14/2023
 TITLE OF EMPLOYER OR AUTHORIZED REPRESENTATIVE
Onboarding Coordination

LAST NAME OF EMPLOYER OR AUTHORIZED REPRESENTATIVE FIRST NAME OF EMPLOYER OR AUTHORIZED REPRESENTATIVE EMPLOYER'S BUSINESS OR ORGANIZATION NAME
Campos Raquel USLSOL

EMPLOYER'S BUSINESS OR ORGANIZATION ADDRESS (STREET CITY OR TOWN STATE ZIP

NUMBER AND NAME) Humble TX 77338
18727 Kenswick Dr.

Employee Name from Section 1: LAST NAME (FAMILY NAME) FIRST NAME (GIVEN NAME) MIDDLE INITIAL
West Derrick J

Section 3. Reveri cation 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) M.I.

B. Date of Rehire (if applicable)

DATE (MM/DD/YYYY)

C. If the employee's previous grant of employment authorization has expired, provide the information for the document or
receipt that establishes continuing employment authorization in the space provided below

DOCUMENT TITLE DOCUMENT NUMBER EXPIRATION DATE (IF ANY) (MM/DD/YYY)

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 TODAY'S DATE (MM/DD/YYYY)

NAME OF EMPLOYER OR AUTHORIZED REPRESENTATIVE

 LISTS OF ACCEPTABLE DOCUMENTS
All documents must be UNEXPIRED
Employees may present one selection from List A
or a combination of one selection from List B and one selection from List C.

LIST A LIST B LIST C

OR AND
Documents that Establish Both Documents that Establish Identity Documents that Establish
Identity and Employment Employment Authorization
Authorization 1. Driver's license or ID card
issued by a State or outlying 1. A Social Security Account
1. U.S. Passport or U.S. Passport possession of the United Number card, unless the card
Card States provided it contains a includes one of the following
photograph or information restrictions:
2. Permanent Resident Card or such as name, date of birth,
tration Receipt Card (Form I- gender, height, eye color, and i. NOT VALID FOR
551) address EMPLOYMENT
3. Foreign passport that contains 2. ID card issued by federal, state ii. VALID FOR WORK ONLY
a temporary I-551 stamp or or local government agencies WITH INS
temporary I-551 printed or entities, provided it contains AUTHORIZATION
notation on a a photograph or information
machinereadable immigrant iii. VALID FOR WORK ONLY
such as name, date of birth,
visa WITH DHS
gender, height, eye color, and
AUTHORIZATION
address
4. Employment Authorization
Document that contains a 2. Certi cation of report of birth
3. School ID card with a
photograph (Form I-766) issued by the Department of
photograph
State (Forms DS-1350, FS-545,
5. For a nonimmigrant alien 4. Voter's registration card FS-240)
authorized to work for a
speci c employer because of 5. U.S. Military card or draft 3. Original or certi ed copy of
his or her status: record birth certi cate issued by a
State, county, municipal
a. Foreign passport; and 6. Military dependent's ID card authority, or territory of the
United States bearing an
b. Form I-94 or Form I-94A 7. U.S. Coast Guard Merchant o cial seal
that has the following: Mariner Card
4. Native American tribal
i. The same name as 8. Native American tribal document
the passport; and document
5. U.S. Citizen ID Card (Form I-
ii. An endorsement of 9. Driver's license issued by a 197)
the alien's Canadian government
nonimmigrant authority 6. Identi cation Card for Use of
status as long as Resident Citizen in the United
that period of For persons under age 18 States (Form I-179)
endorsement has who are unable to present a
not yet expired and document listed above: 7. Employment authorization
the proposed document issued by the
10. School record or report card Department of Homeland
employment is not
in con ict with any Security
11. Clinic, doctor, or hospital
restrictions or record
limitations
identi ed on the 12. Day-care or nursery school
form. record
6. Passport from the Federated
States of Micronesia (FSM) or
the Republic of the Marshall
Islands (RMI) with Form I-94 or
Form I-94A indicating
nonimmigrant admission
under the Compact of Free
Association Between the
United States and the FSM or
RMI

Examples of many of these documents appear in Part 8 of the Handbook for Employers (M-274).
Refer to the instructions for more information about acceptable receipts.
Form I-9 10/21/2019
Invitation to Self-Identify
As a Government contractor subject to VEVRAA, we are required to submit a report to the United States Department of
Labor each year identifying the number of our employees belonging to each specified "protected veteran" category. If you
believe you belong to any of the categories of protected veterans listed below, please indicate by checking the appropriate
box below.

Categories of Protected Veterans

[ ] I belong to the following classifications of protected veterans (choose all that apply):
[ ] Disabled Veteran

[ ] Recently Separated Veteran

[ ] Active Wartime or Campaign Badge Veteran

[ ] Armed Forces Service Medal Veteran

[ ] I am a protected veteran, but I choose not to self-identify the classifications to which I belong.
[X] I am NOT a protected veteran.

If you are a disabled veteran it would assist us if you tell us whether there are accommodations we could make that would
enable you to perform the essential functions of the job, including special equipment, changes in the physical layout of the
job, changes in the way the job is customarily performed, provision of personal assistance services or other
accommodations. This information will assist us in making reasonable accommodations for your disability.

Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The
information provided will be used only in ways that are not inconsistent with the Vietnam Era Veterans' Readjustment
Assistance Act of 1974, as amended.

The information you submit will be kept confidential, except that (i) supervisors and managers may be informed regarding
restrictions on the work or duties of disabled veterans, and regarding necessary accommodations; (ii) first aid and safety
personnel may be informed, when and to the extent appropriate, if you have a condition that might require emergency
treatment; and (iii) Government officials engaged in enforcing laws administered by the Office of Federal Contract
Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed.

Signature
SIGNED DATE
Derrick West 08/10/2023
 Form CC-305
OMB Control Number 1250-0005
Expires 05/31/2023

Voluntary Self-Identification of Disability

Why are you being asked to complete this form?

We are a federal contractor or subcontractor required by law to provide equal employment opportunity to qualified people
with disabilities. We are also required to measure our progress toward having at least 7% of our workforce be individuals
with disabilities. To do this, we must ask applicants and employees if they have a disability or have ever had a disability.
Because a person may become disabled at any time, we ask all of our employees to update their information at least every
five years.

Identifying yourself as an individual with a disability is voluntary, and we hope that you will choose to do so. Your answer
will be maintained confidentially and not be seen by selecting officials or anyone else involved in making personnel
decisions. Completing the form will not negatively impact you in any way, regardless of whether you have self-identified
in the past. For more information about this form or the equal employment obligations of federal contractors under Section
503 of the Rehabilitation Act, visit the U.S. Department of Labor's Office of Federal Contract Compliance Programs
(OFCCP) website at www.dol.gov/ofccp.

How do you know if you have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially
limits a major life activity, or if you have a history or record of such an impairment or medical condition. Disabilities
include, but are not limited to:

• Autism • Deaf or hard of hearing • Missing limbs or partially missing limbs

• Autoimmune disorder, for example, • Depression or anxiety • Nervous system condition for example,
lupus, fibromyalgia, rheumatoid arthritis, • Diabetes migraine headaches, Parkinson's disease,
or HIV/AIDS • Epilepsy or Multiple sclerosis (MS)
• Blind or low vision • Gastrointestinal disorders, for • Psychiatric condition, for example,
• Cancer example, Crohn's Disease, or irritable bipolar disorder, schizophrenia, PTSD, or
• Cardiovascular or heart disease bowel syndrome major depression
• Celiac disease • Intellectual disability
• Cerebal palsy

Please select one of the options below:

I Don't Wish to Answer

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond
to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5
minutes to complete.

FIRST NAME LAST NAME

Derrick West
Signature
SIGNED DATE
Derrick West 08/10/2023
 CRIMINAL BACKGROUND QUESTIONNAIRE

(Not/or use in New York)

NAME DATE

Derrick West 08/10/2023

HAVE YOU EVER BEEN CONVICTED OF A CRIMINAL OFFENSE THAT HAS NOT BEEN EXPUNGED, SEALED, PARDONED, ANNULLED, DISCHARGED,

STATUTORILY ERADICATED OR DISMISSED UPON CONDITION OF PROBATION?

[ ] Yes [X] No [ ] Record

A CRIMINAL CONVICTION WILL NOT NECESSARILY BE A BAR TO EMPLOYMENT. TO HELP US EVALUATE YOUR APPLICATION, PLEASE DESCRIBE THE

NATURE OF THE OFFENSE FOR WHICH YOU WERE CONVICTED, THE CIRCUMSTANCES SURROUNDING THE COMMISSION OF THE OFFENSE AND YOUR

SUBSEQUENT REHABILITATION:

I certify that the above response is accurate. I understand any omission or misrepresentation is

grounds for withdrawal of my conditional offer or discovered during employment grounds for

termination.

NAME SIGNATURE DATE

Derrick West 08/10/2023

Consumer or Investigative Consumer Report- FEDERAL DISCLOSURE

DISCLOSURE OF INTENT TO OBTAIN CONSUMER REPORT OR INVESTIGATIVE CONSUMER REPORT

FOR EMPLOYMENT PURPOSES

Please be advised that USLSOL may use a consumer reporting agency to obtain a consumer report ("Report") or

investigative consumer report as part of its hiring process. Further, please be advised that if you are hired, to the

extent permitted by law, US Logistics Solutions may obtain further Reports from a consumer reporting agency so as

to update, renew, or extend your employment.

Reports provided by a consumer reporting agency may include information regarding your character, general

reputation, personal characteristics, mode of living, and credit standing.

I acknowledge receipt of the separate document entitled SUMMARY OF YOUR RIGHTS UNDER THE FAIR

CREDIT REPORTING ACT and certify that I have read and understand said document.

AUTHORIZATION AND CONSENT TO OBTAIN CONSUMER REPORT OR INVESTIGATIVE CONSUMER

REPORT FOR EMPLOYMENT PURPOSES AND STATE DISCLOSURES

Consistent with the written disclosure provided to me, I hereby consent to and authorize US Logistics Solutions, Inc.

(the "COMPANY") to obtain a consumer report and/or investigative consumer report ("REPORT") from a consumer

reporting agency for employment purposes as part of the COMPANY'S hiring process. If hired, I also consent to the

COMPANY obtaining further Reports from a consumer reporting agency for an employment purpose at any time

during employment.

If an investigative consumer report is requested, I understand that I may request a copy of the federal Fair Credit

Reporting Act Summary of Rights as well as information regarding the nature of any such requested investigative

consumer report.

I hereby provide my ongoing consent for the COMPANY to procure Reports from a consumer reporting agency.

NAME SOCIAL SECURITY NUMBER

Derrick West 450-93-5860

SIGNATURE DATE

Derrick West 08/10/2023

ACKNOWLEDGMENT REGARDING PENDING CRIMINAL

BACKGROUND SEARCH

The Company conducts local and national criminal background checks for all applicants in accordance with

applicable state and federal laws. Obtaining criminal records from local county courts and law enforcement agencies

can sometimes take a significant amount of time. In order to prevent any unnecessary delay in the commencement of

your employment, the Company will allow you to start working for the Company while the Company awaits receipt

of the local criminal background search.

EMPLOYEE NAME
Accordingly, I Derrick West , acknowledge by signing below that the Company is currently waiting on

the results of its local background search: moreover, I acknowledge that my onboarding, orientation or employment
with the Company may be terminated if the results of the local criminal background search, once received, are not

acceptable to the Company. My status with the Company shall remain at all time that of an at-will employee.

EMPLOYEE NAME EMPLOYEE SIGNATURE DATE

Derrick West 08/10/2023

Pending Signature: When ready, enter your name and today's date and click the "Sign and Submit" button.

Click "Save and Exit" to save all entries and return to finish this form later.

Background Information Required

Full Name

FIRST NAME LAST NAME M.I.

Derrick West

Address

STREET ADDRESS APARTMENT NUMBER

401 South Bender 1605

CITY COUNTY (REQUIRED) STATE ZIP CODE

Humble Harris Texas 77338

DATE OF BIRTH SOCIAL SECURITY NUMBER

01/02/1982 450-93-5860

DRIVER'S LICENSE NUMBER STATE EXP DATE

01/02/2025

PHONE EMAIL ADDRESS

MARITAL STATUS

[X] Single [ ] Married

EMERGENCY CONTACT NAME

Precious Moore
RELATIONSHIP

Mother

PHONE

832-965-5434
 Name: Derrick West
Date: 8/10/2023

Electronically Submitted by: 7965-bettathanbefoe@gmail.com

Received: Thu, 10 Aug 2023 12:26:28 GMT
From: 172.58.100.236, 10.200.220.146
Task: Employee Handbook
 ACKNOWLEDGMENT AND RECEIPT OF EMPLOYEE HANDBOOK

This Employee Handbook is an important document intended to help you become acquainted with USLS. This Handbook

will serve as a guide and the Company reserves the right of interpretation of policy. Please read the following statements
and sign below to indicate your receipt and acknowledgment of the Employee Handbook and your understanding of the

statements.

I have received a copy of the Handbook and understand that it is my responsibility to read and comply with the

Employee Handbook. I understand that I may address any questions about the Handbook to Human Resources or my
Supervisor / Manager.

I understand that the policies and benefits described in the Handbook are subject to change at the Company’s sole

discretion at any time, without prior notice. I further understand that the Handbook is not intended as an express or
implied contract for employment, benefits, or other terms and conditions of employment between the Company and

any of its employees.

I understand that my employment with the Company is at-will and that I have the right to terminate my employment

with the Company at any time, with or without cause or notice. In turn, I acknowledge that the Company has the
right to terminate my employment at any time, with or without cause or notice, at its sole discretion.

I understand that my signature below indicates that I have read and understand the above statements, that any questions I

had have been answered to my satisfaction, and that I have received a copy of the Handbook.

Signature

EMPLOYEE NAME EMPLOYEE SIGNATURE DATE

Derrick West Derrick West 08/10/2023

 Photography/Social Media Release Form

I, Derrick West hereby acknowledge that this Photography/Social Media Release Form (hereinafter

referred to as “Form”) became effective on 08/10/2023

I hereby authorize US Logistics Solutions, Inc to edit, change, copy, and make any use of all photographs of me to
be used for promotional materials.

I hereby acknowledge that I will not be entitled to payment or any sort of charge for such action.
I authorize the use of my photographs for, but not limited to, publication on the internet, magazines, journals, books,

articles, etc.… provided that it is done for lawful purposes.

Upon the usage of my photographs, I consent to such materials becoming the sole property of US Logistics

Solutions, Inc and that I will no longer be entitled to them, provided that it is done for lawful purposes.

I hereby release all right to any, but not limited to, claims, rights, demands, and/or any causes of action by me or my

representatives, heirs or anyone else.

Furthermore, I hereby waive my right to any royalty or any other compensation with regard to the usage of the
photos referred to in this form.

Signature

EMPLOYEE PRINTED NAME EMPLOYEE SIGNATURE DATE

Derrick West Derrick West 08/10/2023

 Name: Derrick West
Date: 8/10/2023

Electronically Submitted by: 7965-bettathanbefoe@gmail.com

Received: Thu, 10 Aug 2023 12:28:16 GMT
From: 172.58.100.236, 10.200.220.146
Task: Benefit Enrollment Guide
 Name: Derrick West
Date: 8/10/2023

Electronically Submitted by: 7965-bettathanbefoe@gmail.com

Received: Thu, 10 Aug 2023 12:28:45 GMT
From: 172.58.100.236, 10.200.220.146
Task: Wage Deduction Authorization Form (ENG)
 Name: Derrick West
Date: 8/10/2023

Electronically Submitted by: 7965-bettathanbefoe@gmail.com

Received: Thu, 10 Aug 2023 12:29:13 GMT
From: 172.58.100.236, 10.200.220.146
Task: Benefits Acknowledgement Page
 Name: Derrick West
Date: 8/10/2023

Electronically Submitted by: 7965-bettathanbefoe@gmail.com

Received: Thu, 10 Aug 2023 12:30:15 GMT
From: 172.58.100.236, 10.200.221.25
Task: Photo Social Media Release Form (ENG)
 verifies the Electronic Signature of this document

SIGNATURE

Signer Name: Derrick West

User ID: dbtswest33

Date Electronically Oct 1, 2023 04:31 PM EDT

Signed:

File Name: New Hire Packet - Derrick West.pdf

Display Name: New Hire Packet - Derrick West