KEA , INC. JOB APPLICATION6612 SIX FORKS RD. SUITE # 203 RALEIGH , NC. 27615 (p) 919-847-3701 (F) 919-847-3721

DATE: _____/_________/ 2012

NAME:______________________________________________________________________________ FIRST MIDDLE LAST

ADDRESS: __________________________________________________

__________________________________________________

HOME PHONE: ___________________________ CELL PHONE:________________________________

SOCIAL SECURITY #: _______________________ DATE OF BIRTH: ______________________________

DRIVERS LICENSE SATE: ____________________ LICENSE #:___________________________________

STATUS: SINGLE MARRIED DIVORCED SEPARATED WIDOWED OTHER

Number of DEPENDENTS ____________

EMERGENCY CONTACT NAME: ____________________________________________________________

PHONE:_________________________________ RELATIONSHIP:_______________________________

ARE YOU AUTHORIZED TO WORK IN THE U.S.? YES NO

HAVE YOU EVER BEEN CONVICTED OF A FELONY? YES NO IF YES PLEASE EXPLAIN WHEN AND WHY?

WHAT POSITION ARE YOU APPLYING FOR? __________________________________________________

HAVE YOU WORKED FOR THIS COMPANY BEFORE? YES NO

WHEN ARE YOU AVAILABLE TO START? _____________________________

_____________________________________________________________________________________ EMPLOYMENT STATUS: FULL TIME / PART TIME / 1099

OFFICE USE ONLY: DT ____ DATE: ____-_____- 2012N____ P____

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NAME / NOMBRE

PLEASE CHECK ALL THE SKILLS THAT YOU HAVE.

POR FAVOR REVISE TODAS LAS HABILIDADES

ELECTRICIAN / ELECTRISTA CARPENTER / CARPINTERO

CRANE OPERATOR / OPERADOR DE GRUA APAREJO SITE SAFETY MANAGER / GERENTE DE SEGURIDAD

PLUMBER /FONTANERO DRYWALLER / PANELES DE YESO LABORER / OBRERO HVAC ELEVATOR / ASCENSOR MECHANIC / MECANICO SUPERINTENDENT / SUPERINTENDENTE

IRON WORKER / DEL HIERRO

PAINTER / PINTOR

PROJECT MANAGER / EL DIRECTOR DEL PROJECTO

ACCOUNTANT / CONTADOR SCISSOR LIFT / TIJERA AERIAL LIFT / TENEDOR ASCENSOR CPR OSHA 10/30/500/501 SCAFFOLDING / ANDAMIO

FALL PROTECTION / PROTECCION CONTRA CAIDAS

CONCRETE / CONCRETO CONCRETE FINISHERS

SCAFFOLDING STRIPPERS WELDER

COMMERCIAL/RESIDENTIAL CLEANING FRAMING

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WORK HISTORY Please list your last 3 employers starting with the most recent.

Company Name _______________________________________________________________________

Company Address ______________________________________________________________________

Telephone Number ___________________________________

Supervisor’s Name _____________________________________________________________________

Dates Worked: From __________ __ To ______________

Worked Performed _____________________________________________________________________

_____________________________________________________________________________________

Company Name _______________________________________________________________________

Company Address ______________________________________________________________________

Telephone Number ___________________________________

Supervisor’s Name _____________________________________________________________________

Dates Worked: From __________ __ To ______________

Worked Performed _____________________________________________________________________

_____________________________________________________________________________________

Company Name _______________________________________________________________________

Company Address ______________________________________________________________________

Telephone Number ___________________________________

Supervisor’s Name _____________________________________________________________________

Dates Worked: From __________ __ To ______________

Worked Performed _____________________________________________________________________

_____________________________________________________________________________________

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EDUCATIONAL BACKGROUND

Name and Location Graduate?-Degree? Major/Subjects of Study

HIGH SCHOOL

COLLEGE OR UNIVERSITY

TRADE SCHOOL

OTHER EDUCATION

Please list your areas of highest proficiency, special skills or other items that my contribute to your abilities in performing the job you are applying for.

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

CERTIFICATIONS / LICENSES

_____________________________________________________________________________________________________

______________________________________________________________________________________________________

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Form W-4 (2012)Purpose. Complete Form W-4 so that youremployer can withhold the correct federal incometax 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 adependent on his or her tax return, you cannot claim exemption from withholding if your income exceeds $950 and includes more than $300 of unearnedincome (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 itemizeddeductions, 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 aworking 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, beforecompleting 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.)A Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . . A

B Enter “1” if: { • You are single and have only one job; or• 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.

} B

C 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

D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . . DE Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . . EF 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.) G 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.

• 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 . . . GH 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.) ▶ H

For accuracy, complete allworksheetsthat apply. {

• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions and Adjustments Worksheet on page 2. • 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 avoid having too little tax withheld.• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.

Separate here and give Form W-4 to your employer. Keep the top part for your records.

Form W-4Department of the Treasury Internal Revenue Service

Employee's Withholding Allowance Certificate▶ 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.

OMB No. 1545-0074

20121 Your first name and middle initial Last name

Home address (number and street or rural route)

City or town, state, and ZIP code

2 Your social security number

3 Single Married Married, but withhold at higher Single rate.

Note. If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.

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. ▶

5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 56 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6 $

7 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 . . . . . . . . . . . . . . . ▶ 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.) ▶ Date ▶

8 Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.) 9 Office code (optional) 10 Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 10220Q Form W-4 (2012)

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North Carolina Department of Revenue

Employee�s WithholdingAllowance Certicate

NC-4

Single Head of Household Married or Qualifying Widow(er)Marital Status

(Employer: Complete below only if sending to the North Carolina Department of Revenue. Submit the original and keep a copy for your records.)

CAUTION: If you furnish an employer with an Employee’s Withholding Allowance Certicate that contains information which has no reasonable basis and results in a lesser amount of tax being withheld than would have been withheld had you furnished reasonable information, you are subject to a penalty of 50% of the amount not properly withheld.

I certify, under penalties provided by law, that I am entitled to the number of withholding allowances claimed on line 1 above, or if claiming exemption from withholding, that I am entitled to claim the exempt status on line 3 or 4, whichever applies.

Employee�s Signature Date

If line 3 or line 4 above applies to you, enter the year effective and write �EXEMPT� here

1. Total number of allowances you are claiming(From Line F of the Personal Allowances Worksheet on Page 2)

Additional amount, if any, you want withheld from each pay period(Enter whole dollars)

2. 00.

� This year I expect a refund of all State income tax withheld because I expect to have no tax liability.

I certify that I am not subject to North Carolina withholding because I meet the following two conditions:

5. I certify that I no longer meet the requirements for exemption on line 3 or line 4 (Check applicable box)Therefore, I revoke my exemption and request that my employer withhold North Carolina income taxbased on the number of allowances entered on line 1 and any amount entered on line 2. Check Here

Check Here� Last year I was entitled to a refund of all State income tax withheld because I had no tax liability; and 3.

Check HereI certify that I am not subject to North Carolina withholding because I meet the requirementsof the Military Spouses Residency Relief Act and I am legally domiciled in the state of

____________________________________________.

4.

(See Form NC-4 Instructions before completing this form)

Social Security Number

Last NameFirst Name (USE CAPITAL LETTERS FOR YOUR NAME AND ADDRESS) M.I.

Address County (Enter rst ve letters)

City Country (If not U.S.)State Zip Code (5 Digit)

,

2 0

Employer�s Name FEIN(USE CAPITAL LETTERS)

Employer�s Address County (Enter rst ve letters)

City Country (If not U.S.)State Zip Code (5 Digit)

Web12-09

(Enter state of domicile)

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AUTHORIZATION FOR BACKGROUND CHECK

(Please read and sign this form in the space provided below. Your written authorization is

necessary for completion of the application process.)

Signature of Employee Date

Employee's Name - Printed

I, , hereby authorize KEA to investigate my (Local and

nationally) background and qualifications for purposes of evaluating whether I am qualified

for the position for which I am applying. I understand that KEA will utilize an outside firm or

firms to assist it in checking such information, and I specifically authorize such an

investigation by information services and outside entities of the company's choice. I also

understand that I may withhold my permission and that in such a case, no investigation will be

done, and my application for employment will not be processed further.

KEA919-847-3701 6612 Six Forks Rd Raleigh, NC 27615

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Drug Test Consent Form

CONSENT FOR PRE-EMPLOYMENT, RANDOM, OR REASONABLE SUSPICION DRUG

TEST SCREEN AND RELEASE COVENANT NOT TO SUE AND INDEMNITY AGREEMENT

CURRENT MEDICATIONS

PRESCRIPTIONS & NON-PRESCRIPTION

__________________________________

__________________________________ __________________________________ __________________________________

______________________ (SIGNATURE)

_______________________ (NAME PRINTED)

________________________ (SOCIAL SECURITY NUMBER)

I hereby CONSENT to allow KEA to take a specimen of my hair, urine, or blood and submit it for a pre-employment, random, or reasonable suspicion drug test screen. I FURTHER CONSENT to allow the laboratory testing service to make the results of such screen available to the prospective or current employer, KEA.

In consideration for such services being rendered on my behalf, I hereby RELEASE the laboratory testing service, its officers, agents, and employees, from any and all claims which I might otherwise have due to such results being made so available. I hereby CONSENT NOT TO FILE ANY ACTION at law or in equity against KEA. the laboratory testing service, their respective officers, agents or employees in connection with the results of such screen being made so available, and I hereby agree to INDEMNIFY and SAVE HARMLESS KEA. the laboratory testing service, their respective officers, agents, and employees from all damages, expenses, reasonable attorney's fees, and costs of court which they or any of them may suffer or incur, jointly or severally, due to the results of such screen being made so available.

SIGNED this ___________day of _____________, 2013

KEA919-847-3701 6612 Six forks Rd. Suite 203 Raleigh, North Carolina 27615

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