Employment Application
List your name exactly as it appears on your Social Security Card to ensure proper tax credit.
Full Name Last
First
List all names used in past
SSN #__ __ __ - __ __ - __ __ __ __
Nickname
Mailing Address
Apt. #
City
State
Phone (
)
Cell (
)
Emergency contact?
Have you ever been
convicted of a crime?
Type of work desired
Phone
No
OT ok?
Pay Desired
Internet
Message (
Text ok
Yes
How did you hear about us?
Zip
Email:
Temporary
Permanent
Full-time
Part-time
Today’s Date:
MI
)
(
Newspaper _________________________
)
A conviction record does not automatically disqualify an applicant from employment.
We do require a background check, to determine eligibility for particular employment
Education
$__________
Salary Desired $__________
M/PhD
Trade School
Other
High School / GED
Some College
AA
BA/BS
_________________________
Friend
_________________________
Other
_________________________
Over 18 years of age?
Yes
No
Degree:
Year:
Certification:
Name of institution
Employment History
From:
To:
Reason for leaving
Company Name:
Supervisor's Name
Job Title:
Ph:
Company Address:
Contact your supervisor?
City
From:
To:
Reason for leaving
State
To:
Reason for leaving
Salary – Starting:
Company Name:
Supervisor's Name
Job Title:
Ph:
Company Address:
Contact your supervisor?
State
City
From:
Zip
Zip
Salary – Starting:
Company Name:
Supervisor's Name
Job Title:
Ph:
Company Address:
Contact your supervisor?
City
State
Zip
Salary – Starting:
Yes
No
Ending:
Yes
No
Ending:
Yes
No
Ending:
Other Employment
Worked for or applied with TERRA/Allstaff in the past?
Staffing Service
Client Company
Yes
No Year: _____
Worked with a staffing service before?
Temporary Contact
Job Duties
Yes
No
Salary
List your top 3 positions in order of preference:
1)
2)
3)
Other Known Languages:
TERRA will not use any information provided to discriminate on the basis of race, color, religion, national origin,
marital status, sex, sexual orientation, disability, age or any other classification protected by law.
Accounting
Skills
– Audit Accounting
– Accounts Payable
– A/P Coding
– Accounts Receivable
– Credit & Collections
– Cost Accounting
– Big 4 Acctg Firms
– Billing
– General Ledger
– Financial Statements
– Job Costing
– Payroll
– Profit & Loss
– Quarterly Reports
– Reconciliation
Operational
– Accounting Clerk
– Accounting Manager
– Assistant Controller
– Billing Manager
– Bookkeeper
– Controller
– CPA
– Credit Manager
– A/P Manager
– A/R Manager
– Payroll Manager
– Public Accounting
– Staff Accounting
– Tax Accounting
Financial
– Budgeting
– CFO
– Credit Analyst
– Finance
– Financial Analyst
– Finance Auditing
– Financial Reporting
– Investments
– Portfolio Mgmt.
– SEC Reporting
– Treasurer
– VP Accounting
– VP Finance
Accounting Software
– Dynamics
– Great Plains
– Peachtree
Payroll Software
– ADP Payroll
– Ceridian
– Payroll Union
Office Use
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___ E G K
___ E G K
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___ E G K
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C
C
C
C
C
C
C
Administrative
Skills
– Customer Service
– Data Entry
– Alpha
– Numeric
– Filing
– Graphic Design
– File Clerk
– Help Desk
– Inventory
– Mailroom
Position
– Administrative Asst
– Sr. Admin Assistant
– Events Coordinator
– Executive Assistant
– Office Assistant
– Office Management
– Project Coordinator
– Project Management
– Reception
– Research Assistant
– Sales Coordinator
– Switchboard
– Transcription
– Word Processing
Banking
– Teller
– Loan Doc Specialist
– Loan Office
– Loan Processor
– Sr. Loan Officer
– Consumer Loan
Health Care
– Medical Records
– Medical Billing
– HCFA-1500
– ICD-9
– CPT-4
– Medical Receptionist
– Medical Secretary
– Medical Terminology
– Medical Records
Human Resources
– HR Assistant
– HR Clerk
– HR Comp & Benefits
– HR Generalist
– HR Labor Relations
– HR Manager
– HR Recruiting/Staffing
– HR Safety/Workers Comp
– HR Training & Dvlpmnt
Office Use
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C
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C
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Manufacturing
– Blue Print Reading
– Buyer
– Purchasing
– Planner
– Manufacturing Sales
Sales & Marketing
– Call Center
– Inside Sales
– Marketing Assistant
– Marketing Director
– Marketing Manager
– Public Relations
– Telephone Sales
Software
– Adobe FrameMaker
– Adobe Illustrator
– Adobe PhotoShop
– Crystal Reports
– Desktop Publishing
– Dreamweaver
– Lotus Notes
– MS Access
– MS Excel
– MS Office
– MS Outlook
– MS Photo Editor
– MS PowerPoint
– MS Project
– MS Publisher
– MS Visio
– MS Word
– Oracle
– QuickBooks
– Quicken
Industry
– Accounting/CPA
– Aerospace
– Architecture
– Banking/Finance
– Education
– Construction
– Engineering
– Food Service
– Forestry
– Government
– High Tech
– Hospitality
– Insurance
– Legal
– Manufacturing
– Marketing
– Medical/Dental
– Mental Health
– Mortgage
– Non-Profit
Office Use
___ E G K C
___ E G K C
___ E G K C
___ E G K C
___ E G K C
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I certify that the statements I have provided on the application (and in my resume, if provided) are true, complete and correct and contain no errors, omissions,
falsifications, misrepresentations, or misleading statements. If I am offered employment, I understand and agree that any error, omission, falsification,
misrepresentation or misleading statement on the application or resume will be grounds for immediate termination regardless of when the error, omission,
falsification, misrepresentation, misleading statement is discovered. I also understand my employment may be contingent upon successful completion of a
drug test and background check. I understand that while on a temporary or temp-to-hire assignment I am an employee of TERRA Companies (TERRA
Staffing Group) and as such must direct questions regarding attendance, compensation and benefits, or grievances to any TERRA Staffing Supervisor. Upon
completion of each assignment and on a regular basis thereafter, I agree that if I do not continue to contact TERRA for work I may be considered unavailable
and that I have terminated my employment with them. I authorize TERRA to contact my past employers for the purpose of verifying statements contained on
my employment application. I release former employers and TERRA from any liability arising from disclosure of any information pertaining to me obtained
during said investigation. I authorize TERRA to contact any person to verify any of the information I have provided. I hereby release from liability any person
who provides any information about me to TERRA. I understand and agree that employment, if offered, will continue at the will of TERRA and myself and
may be terminated at any time, for any reason, with or without notice or cause, by either me or TERRA. My employment with the company will remain
terminable at will, not withstanding any other oral or written statements by the company, at or following my date of employment, except as provided in a
separate writing, signed by the president of the company, which expressly provides for different termination provisions.
I CERTIFY THAT I HAVE CAREFULLY READ THE IMPORTANT NOTICE SET FORTH ABOVE IN ITS ENTIRETY.
Signature
Date
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Form W-4 (2012)
Purpose. Complete Form W-4 so that your
employer can withhold the correct federal income
tax from your pay. Consider completing a new Form
W-4 each year and when your personal or financial
situation changes.
Exemption from withholding. If you are exempt,
complete only lines 1, 2, 3, 4, and 7 and sign the
form to validate it. Your exemption for 2012 expires
February 18, 2013. See Pub. 505, Tax Withholding
and Estimated Tax.
Note. If another person can claim you as a
dependent on his or her tax return, you cannot claim
exemption from withholding if your income exceeds
$950 and includes more than $300 of unearned
income (for example, interest and dividends).
Basic instructions. If you are not exempt, complete
the Personal Allowances Worksheet below. The
worksheets on page 2 further adjust your
withholding allowances based on itemized
deductions, certain credits, adjustments to income,
or two-earners/multiple jobs situations.
Complete all worksheets that apply. However, you
may claim fewer (or zero) allowances. For regular
wages, withholding must be based on allowances
you claimed and may not be a flat amount or
percentage of wages.
Head of household. Generally, you can claim head
of household filing status on your tax return only if
you are unmarried and pay more than 50% of the
costs of keeping up a home for yourself and your
dependent(s) or other qualifying individuals. See
Pub. 501, Exemptions, Standard Deduction, and
Filing Information, for information.
Tax credits. You can take projected tax credits into
account in figuring your allowable number of
withholding allowances. Credits for child or
dependent care expenses and the child tax credit
may be claimed using the Personal Allowances
Worksheet below. See Pub. 505 for information on
converting your other credits into withholding
allowances.
Nonwage income. If you have a large amount of
nonwage income, such as interest or dividends,
consider making estimated tax payments using Form
1040-ES, Estimated Tax for Individuals. Otherwise, you
may owe additional tax. If you have pension or annuity
income, see Pub. 505 to find out if you should adjust
your withholding on Form W-4 or W-4P.
Two earners or multiple jobs. If you have a
working spouse or more than one job, figure the
total number of allowances you are entitled to claim
on all jobs using worksheets from only one Form
W-4. Your withholding usually will be most accurate
when all allowances are claimed on the Form W-4
for the highest paying job and zero allowances are
claimed on the others. See Pub. 505 for details.
Nonresident alien. If you are a nonresident alien,
see Notice 1392, Supplemental Form W-4
Instructions for Nonresident Aliens, before
completing this form.
Check your withholding. After your Form W-4 takes
effect, use Pub. 505 to see how the amount you are
having withheld compares to your projected total tax
for 2012. See Pub. 505, especially if your earnings
exceed $130,000 (Single) or $180,000 (Married).
Future developments. The IRS has created a page
on IRS.gov for information about Form W-4, at
www.irs.gov/w4. Information about any future
developments affecting Form W-4 (such as
legislation enacted after we release it) will be posted
on that page.
Personal Allowances Worksheet (Keep for your records.)
Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . .
A
• You are single and have only one job; or
Enter “1” if:
B
• You are married, have only one job, and your spouse does not work; or
. . .
• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.
Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or more
than one job. (Entering “-0-” may help you avoid having too little tax withheld.) . . . . . . . . . . . . . .
C
Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . .
D
Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . .
E
Enter “1” if you have at least $1,900 of child or dependent care expenses for which you plan to claim a credit
. . .
F
(Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)
Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.
• If your total income will be less than $61,000 ($90,000 if married), enter “2” for each eligible child; then less “1” if you have three to
seven eligible children or less “2” if you have eight or more eligible children.
A
{
B
C
D
E
F
G
}
• If your total income will be between $61,000 and $84,000 ($90,000 and $119,000 if married), enter “1” for each eligible child . . .
G
Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.) a H
• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions
For accuracy,
and Adjustments Worksheet on page 2.
complete all
• If you are single and have more than one job or are married and you and your spouse both work and the combined
earnings from all jobs exceed $40,000 ($10,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to
worksheets
avoid having too little tax withheld.
that apply.
• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.
H
{
Separate here and give Form W-4 to your employer. Keep the top part for your records.
Form
W-4
Department of the Treasury
Internal Revenue Service
1
Employee's Withholding Allowance Certificate
OMB No. 1545-0074
a Whether you are entitled to claim a certain number of allowances or exemption from withholding is
subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
Your first name and middle initial
Last name
Home address (number and street or rural route)
2
3
Single
Married
2012
Your social security number
Married, but withhold at higher Single rate.
Note. If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.
City or town, state, and ZIP code
4 If your last name differs from that shown on your social security card,
check here. You must call 1-800-772-1213 for a replacement card. a
5
6
7
Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2)
5
Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . .
6 $
I claim exemption from withholding for 2012, and I certify that I meet both of the following conditions for exemption.
• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and
• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.
If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . a 7
Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.
Employee’s signature
(This form is not valid unless you sign it.)
8
Date a
a
Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.)
9 Office code (optional)
TERRA Services, Inc. 1000 SE Everett Mall Way, Suite 301, Everett, WA 98208-2814
For Privacy Act and Paperwork Reduction Act Notice, see page 2.
10
Employer identification number (EIN)
91-1382999
Cat. No. 10220Q
Form W-4 (2012)
Page 2
Form W-4 (2012)
Deductions and Adjustments Worksheet
Note. Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.
1
2
3
4
5
6
7
8
9
10
Enter an estimate of your 2012 itemized deductions. These include qualifying home mortgage interest,
charitable contributions, state and local taxes, medical expenses in excess of 7.5% of your income, and
miscellaneous deductions . . . . . . . . . . . . . . . . . . . . . . . . .
$11,900 if married filing jointly or qualifying widow(er)
Enter:
$8,700 if head of household
. . . . . . . . . . .
$5,950 if single or married filing separately
Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . .
Enter an estimate of your 2012 adjustments to income and any additional standard deduction (see Pub. 505)
Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to
Withholding Allowances for 2012 Form W-4 worksheet in Pub. 505.) . . . . . . . . . . . .
{
}
Enter an estimate of your 2012 nonwage income (such as dividends or interest) . . . . . . . .
Subtract line 6 from line 5. If zero or less, enter “-0-” . . . . . . . . . . . . . . . .
Divide the amount on line 7 by $3,800 and enter the result here. Drop any fraction . . . . . . .
Enter the number from the Personal Allowances Worksheet, line H, page 1 . . . . . . . . .
Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet,
also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1
1
$
2
$
3
4
$
$
5
6
7
8
9
$
$
$
10
Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.)
Note. Use this worksheet only if the instructions under line H on page 1 direct you here.
Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet)
1
2
Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if
you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more
than “3” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
1
2
If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter
“-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet . . . . . . . . .
3
Note. If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4 through 9 below to figure the additional
withholding amount necessary to avoid a year-end tax bill.
4
5
6
7
8
9
Enter the number from line 2 of this worksheet . . . . . . . . . .
4
Enter the number from line 1 of this worksheet . . . . . . . . . .
5
Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . .
Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . .
Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . .
Divide line 8 by the number of pay periods remaining in 2012. For example, divide by 26 if you are paid
every two weeks and you complete this form in December 2011. Enter the result here and on Form W-4,
line 6, page 1. This is the additional amount to be withheld from each paycheck . . . . . . . .
Table 1
Married Filing Jointly
If wages from LOWEST
paying job are—
Enter on
line 2 above
6
7
8
$
$
9
$
Table 2
All Others
If wages from LOWEST
paying job are—
Married Filing Jointly
Enter on
line 2 above
$0 - $5,000
0
$0 - $8,000
0
1
5,001 - 12,000
8,001 - 15,000
1
2
12,001 - 22,000
15,001 - 25,000
2
3
22,001 - 25,000
25,001 - 30,000
3
4
25,001 - 30,000
30,001 - 40,000
4
5
30,001 - 40,000
40,001 - 50,000
5
6
40,001 - 48,000
50,001 - 65,000
6
7
48,001 - 55,000
65,001 - 80,000
7
8
55,001 - 65,000
80,001 - 95,000
8
9
65,001 - 72,000
95,001 - 120,000
9
10
72,001 - 85,000
120,001 and over
10
85,001 - 97,000
11
12
97,001 - 110,000
13
110,001 - 120,000
14
120,001 - 135,000
15
135,001 and over
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 who claims no
withholding allowances; 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 possessions
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.
If wages from HIGHEST
paying job are—
$0
70,001
125,001
190,001
340,001
- $70,000
- 125,000
- 190,000
- 340,000
and over
Enter on
line 7 above
$570
950
1,060
1,250
1,330
All Others
If wages from HIGHEST
paying job are—
$0
35,001
90,001
170,001
375,001
- $35,000
- 90,000
- 170,000
- 375,000
and over
Enter on
line 7 above
$570
950
1,060
1,250
1,330
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.
Disclosure & Authorization for
Employment Related Consumer Report and Drug Screening
I understand that, as a condition of my consideration for employment, or as a condition of my continued
employment, TERRA Staffing Group may obtain a consumer report that includes, but is not limited to, my
employment and/or education verifications, social security verification, criminal and civil history, DMV
records, any other public records and any other information bearing on my credit standing, character, general
reputation, personal characteristics and trustworthiness.
By signing the release below, I hereby authorize TERRA Staffing Group on behalf of Intelius to contact any
and all corporations, former employers, credit agencies, educational institutions, law enforcement agencies,
city, state, county, and federal courts, military services to release information about my background as stated
above.
I release from all liability all persons, companies, schools supplying such information. I indemnify TERRA
Staffing Group against all liability, which may result from making such requests. This release shall remain in
effect for the length of my employment, if hired. I understand that, pursuant to the federal Fair Credit
Reporting Act, TERRA Staffing Group will provide me with a copy of any such report if the information
contained in such report is, in any way, to be used in making a decision regarding my fitness for employment.
I further understand that such report will be made available to me prior to any such decision being made, along
with the name and address of the reporting agency that produced the report.
I believe to the best of my knowledge that all information I have provided both on the application and this
authorization form is accurate, true and correct and that I fully understand the terms of this release.
SIGNATURE:
PRINT NAME (FIRST, MIDDLE, LAST):
PRINT ANY OTHER NAMES USED:
SOCIAL SECURITY #:
BIRTHDATE (Mo/Day/Year):
DRIVER'S LICENSE NUMBER & STATE (A DMV check will be completed only for jobs that
require driving a company owned vehicle) #______________________State ______________
ADDRESS:
CITY/STATE/ZIP:
OTHER STATES:
EDUCATION VERIFICATION
DATE DEGREE RECEIVED (If applicable):
DEGREE RECEIVED:
Intelius Inc., a consumer reporting agency, will obtain the report for the Company.
Intelius Inc.
500 108th Avenue NE
25th Floor
Bellevue, WA 98004
(425) 974-6100
© Copyright 2026 Paperzz