Sick Leave
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Vacation and Personal days
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Retirement Plan
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Is Unemployment Insurance Carried on the employee Yes No
Is Insurance Available to the employee (Check all that apply)
Life Medical/Health Dental Disability Vision
Please list any other Benefits available to the employee
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
___________________________________________________ _________________________________
Signature of Employer or Employers Representative Date
___________________________________________________ _________________________________
ACDJFS Representative Date
********************************************************************************************
I have read and understand the Company’s Policy Guidelines and Disciplinary Procedures
___________________________________________________ _________________________________
Employee Date
___________________________________________________ _________________________________
ACDJFS Representative Date