OMB No. 1615-0047
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.
I am aware that federal law provides for imprisonment and/or fines 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):
Important Note: The information requested on this form is for the sole purpose of undertaking an employment investigation and may be used for a pre-employment investigation, or from time to time during employment.
If yes, please list offense and the location (county and state) and the date(s) where offense(s) occurred:
If more space is needed, please use additional pages.
List the county and state of your previous places of residence and / or employment (whichever is applicable) during the past seven years.
Fair Credit Reporting Act: I hereby understand that a consumer report may be ordered for employment screening purposes, and that I am hereby giving my permission for such a report to be procured. I understand that I am entitled to see a copy of this report and a copy of “summary of consumer rights” before any adverse action is taken by the below mentioned employer. The information from this report will not be used in violation of any applicable state or federal equal opportunity law or regulation.
In connection with my application for employment or promotion, reassignment, or retention of current employment, I understand that (“Employer”) may conduct a background investigation and compile a consumer report or investigative consumer report in me. This report may include information as to my character, reputation, mode of living, criminal history, military service, education, academic credentials, qualification, employment history (including job performance, experience, work habits and reason for termination), personal characteristics, credit indebtedness, and motor vehicle driving record. This report may contain information from various public and private sources, including without limitation, corporations, courts and law enforcement agencies at the federal, state or local levels, courts record repositories, credit bureaus, departments of motor vehicles, past or present employers, educational institutions, governmental licensing or registration entities, the military business or personal references, and other sources required to verify information that I have voluntary supplied. I understand that I have the right to request additional disclosures as to the nature and scope of the investigative consumer report if processed. Medical and worker’s compensation information will only be requested in compliance with the Federal Americans with Disabilities Act (ADA) and/or any other applicable state laws.
I hereby authorize the company and its agent to verify the information submitted by me and to obtain any credit information, criminal history. Or driving records. Neither the company nor its agent shall be violating my right to privacy in any manner and I release them from all liability whatsoever for actions related to this investigation.
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance coverage, you may in the future be able to enroll yourself or your dependents in this plan, provided that you request enrollment within 31 days after your other coverage ends. In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents, provided that you request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption.
This is to acknowledge that my employer explained the benefit plans available to me. I was given the opportunity to apply for the available benefit plans and have elected not to enroll.
Reason for declining coverage:
*Please include a copy of your insurance card.
Due to changes in the Healthcare Marketplace Effective January 1st 2015, Ocean Detailing will be providing Employer Sponsored Group Medical Coverage with an Insurance Carrier of their choice in compliance with the Federal Health Care Reform Employer Requirement.
As Ocean Detailing will be offering a Group Medical Plan that is in compliance with the Affordable Care Act, Full Time Employees working 29 hours or more will no longer be eligible to obtain an Individual Government Tax Subsidy through the Federal Marketplace after January 1, 2015.
Please be advised, you are not obligated to sign up for the Group Medical Plan, but if you neglect to re-enroll in the Group Medical Policy, the Federal Individual Mandate will apply. You will be responsible to pay a tax penalty at the end of the year for not having Health Insurance Coverage.
Furthermore, if you are currently enrolled in an Individual Medical Plan and are receiving a Government Tax Subsidy, you will also be subject to a Penalty while Ocean Detailing is offering Compliant Group Medical Coverage.
By signing below, I acknowledge that I am waiving Group Medical Coverage as offered by Ocean Detailing in accordance with the Affordable Care Act and will obtain coverage on my own regard and expense.
Thank you for your cooperation during this transition. We appreciate your time and service.
Non-Exclusive Acknowledgement and Consent: I acknowledge that this document is not exclusive and does not contain all of my Employer's workplace policies and procedures, which may be contained in a separate employee handbook to be provided by my Employer.
I hereby certify that all information contained in this employee packet or in any other application, résumé or document provided to my Employer or CoAdvantage is true, accurate and complete, and is provided knowingly and voluntarily.
I understand that providing any false, inaccurate or incomplete information may result in disciplinary action, up to and including termination or my employment.
This is to acknowledge that I have received a copy of OCEAN DETAILING USA MANAGEMENT, INC. (the "Company')Employee Handbook and understand that it sets forth the terms and conditions of my employment as well as the duties, responsibilities, and obligations of employment with the Company. I understand and agree that it is my responsibility to read the Employee Handbook and to abide by the rules, policies and standards set forth in the Employee Handbook.
I also acknowledge that my employment with the company is not for a specified period of time and can be terminated at any time for any reason, with or without cause or notice, by me or by the Company. I acknowledge that no oral or written statements or representations regarding my employment can alter the foregoing. I also acknowledge that no Manager or Employee has the authority to enter into an employment agreement—express or implied—providing for employment other that at will.
I also acknowledge that, except for the policy of at-will employment, the Company reserves the right to revise, delete and add to the provisions of this Employee Handbook. All such revisions, deletions, or additions must be in writing and must be signed by the President of the Company. No oral statements or representations can change the provisions of this Employee Handbook. I also acknowledge that, except for the policy of at-will employment, terms and conditions of employment with the company may be modified at the sole discretion of the company with or without cause or notice at any time. No implied contract concerning any employment-related decision, term of employment, or condition of employment can be established by any other statement, conduct, policy or practice.
I understand that the foregoing agreement concerning my at-will employment status and the Company's right to determine and modify the terms and conditions of employment is the sole and entire agreement between me and the Company concerning the duration of my employment, and the circumstances under which the terms and conditions of my employment may change. I further understand that this agreement supersedes all previous agreements, understandings, and representations concerning my employment with The Company.
I understand that The Company and I will arbitrate all disputes arising out of my employment, and termination of my employment before a neutral arbitrator, and that this arbitration will be binding on the Company and me.
As a condition of employment at OCEAN DETAILING USA MANAGEMENT, INC., (the "Company") The Employee agrees to arbitrate before a neutral arbitrator any and all disputes or claims, which would otherwise be subject to resolution in court, arising from or relating to Employee’s recruitment to, employment with, or termination from the Company, Including claims against any current or former agent or employee of the Company, whether the disputes or claims arises in tort; contract, or pursuant to a statute, regulation or ordinance now in existence or which may In the future be enacted or recognized. All arbitration proceedings shall be conducted pursuant the rules of the American Arbitration Association and be held in Miami, Florida.
In order to increase employee safety and eliminate unnecessary risks behind the wheel, Ocean Detailing USA has enacted a Distracted Driving Policy, effective Sept 1, 2014. We are committed to ending the epidemic of distracted driving, and have created the following rules, which apply to any employee operating a company vehicle or using a company-issued cell phone while operating a personal vehicle:
I acknowledge that I have received a written copy of the Distracted Driving Policy, that I fully understand the terms of this policy, that I agree to abide by these terms, and that I am willing to accept the consequences of failing to follow the policy.