Workplace Background Check Policy
I hereby give my informed consent to the designated Road Dog Industrial Representative and/or its partner companies to conduct a background check. I understand that refusal to submit to a background check may disqualify me from consideration for employment or, if employed, subject me to immediate disciplinary action up to and including immediate discharge.
I certify the the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statement on this application shall be grounds for dismissal.
I authorize investigation of all statements contained herein and the references and employers listed above to give you any information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.
I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.
I also authorize Road Dog Industrial to release the information contained herein and its findings and work history of my employment to other firms or persons upon request. I also understand and agree that I may be expected to work on a wide variety of job assignments and agree to accept assignments for which I am qualified as they become availiable. I also understand my failure to report to Road Dog Industrial for work will indicate I have quit. I also agree to submit to a drug screen upon request or as specified in Road Dog Industrial’s substance abuse policy.
Download Employee Handbook PDF
By signing this I certify that I have read and fully understand Road Dog Industrial’s Employee Handbook and Road Dog Industrial Safety Manual.
Drug Screen Authorization and Consent
I hereby authorize and give full permission to have Road Dog Industrial and/or their medical company physician send a specimen of my urine and/or blood to a laboratory for screening test using Substance Abuse & Mental Health Services Administration (S.A.M.H.S.A.) (
www.samhsa.gov) standards for the presence of illegal drugs, alcohol, or prescription medication taken without a prescription.
I will hold all parties concerned harmless, meaning I will not sue nor hold responsible for any alleged harm to me of interfering with my obtaining a job or continuing employment due to not submitting to the tests or as a result of the report of the tests. This includes, but not limited to, possible clerical or laboratory error.
This policy and authorization has been explained to me in a language I understand and told if I have any questions they will be answered about the test. I understand this is a legal and binding document, which is binding because Road Dog Industrial is sending me for the examinations and paying for it.
I UNDERSTAND ROAD DOG INDUSTRIAL WILL REQUIRE A DRUG SRCEEN TEST WHENEVER AN ON THE JOB ACCIDENT OR INJURY IS REPORTED IN ACCORDANCE WITH THIS STAFFING COMPANY POLICY AND THIS AUTHORIZATION AND CONSENT. MY REFUSAL TO SUBMIT TO DRUG TESTING WILL BE GROUNDS FOR TERMINATION.
Substance Abuse Policy
It is the purpose of Road Dog Industrial to help provide a drug free environment for our clients and our employees. With this goal and because of the serious drug abuse problem in today's workplace, we are establishing the following policy for existing and future employees of Road Dog Industrial:
Road Dog Industrial explicitly prohibits:
The use, possession, solicitation for or sale of narcotics or other illegal drugs, alcohol, or prescription medication that adversely affects the employee's work performance, his or her own or other’s safety at the workplace, or the employer’s reputation.
Road Dog Industrial may drug test using Substance Abuse & Mental Health Services Administration (S.A.M.H.S.A.) (
Employees of Road Dog Industrial who refuse to submit to drug testing, test positive, or admit to substance abuse will be subject to termination.
The results of all drug testing will be treated confidentially, and for no purpose other than for Road Dog Industrial to make employment related decisions.
Policies and Procedures Checklist
I understand Road Dog Industrial takes their responsibility as my employer very seriously, and that they have gone to great lengths to provide a safe work environment. If I am injured on the job, Road Dog Industrial will deal promptly with legitimate claims and has workers compensation insurance that will pay medical expenses and wages. I also understand that Road Dog Industrial has extensive experience investigating claims and will fight fraudulent claims with all available resources.
If I sustain an injury on the job, I will inform the client and Road Dog Industrial within 24 hours, who will coordinate with the client and myself the proper procedures for treatment and reporting of the accident.
Road Dog Industrial has a strict “Substance Abuse Policy", and I have signed a consent form to submit to drug testing. I understand that my failure to comply with this agreement will be grounds for my immediate termination.
I understand and will comply with Road Dog Industrial safety rules and regulations and hazardous communication program.
I understand that I must come prepared with all required tools of the trade and any needed PPE.
I am telephone accessible, and I have reliable transportation.
I understand that I am an employee of Road Dog Industrial and only Road Dog Industrial or I can terminate my employment. When an assignments ends I must report to Road Dog Industrial for my next job assignment.
I understand that I am expected to complete any job assignment I accept. I understand that if I do not complete or promptly notify of my inability to complete the assignment, or if I do not report for my assignment then Road Dog Industrial may assume that I have voluntarily quit.
If for some unexpected reason, such as an emergency or illness, I cannot make it to work or will be late, I will contact Road Dog Industrial and my on-site foreman as soon as possible. Road Dog Industrial may adjust my hourly wage to the Federal Minimum Wage, if I leave the assignment within the first week without written notice.
I understand Road Dog Industrial requirements for receiving information, documenting hours worked, the method of providing the information, and the time frame for me to provide this information. I understand Road Dog Industrial will not recognize or pay for any hours worked by an employee without proper documentation verifying hours worked.
I have read and fully understand the above statements regarding Road Dog Industrial policies and procedures and agree to the same. I understand that failure to comply with these policies and procedures could lead to my termination and may jeopardize my insurance beneﬁts.
General Safety Rules
Road Dog Industrial has developed these safety rules patterned after the Federal OSHA requirements. Read and become familiar with these rules, and other safety rules that apply to your job.
Report an injury to your employer/supervisor within 24 hours.
Report any observed unsafe condition to your employer/supervisor.
Horseplay is prohibited at all times.
The drinking of alcoholic beverages is not permitted on the job. Any employee discovered under the inﬂuence of alcohol or drugs will not be permitted to work.
If you do not have current First Aid Training, do not move or treat an injured person unless there is an immediate peril, such as profuse bleeding or stoppage of breathing.
Appropriate clothing and footwear must be worn on the job at all times.
Where there exists the hazard of falling objects, an approved hard hat must be worn.
You should not perform any task unless you are trained to do so and are aware of the hazards associated with the tasks.
You may be assigned certain personal protective safety equipment. This equipment should be available for use on the job, be maintained in good condition, and worn when required.
Learn safe work practices. When in doubt about performing a task safely, contact your supervisor for instruction and training.
The riding of a hoist hook, or on other equipment not designed for such purposes, is prohibited at all times.
Never remove or by-pass safety devices.
Do not approach operating machinery from the blind side; let the operator see you.
Learn where ﬁre extinguishers and first aid kits are located.
Maintain a general condition of good housekeeping in all work areas at all times.
Obey all traffic regulations when operating vehicles on public highways.
When operating or riding in company vehicles or using your personal vehicle for business purposes, the vehicle's seatbelt shall be worn.
Be alert to hazards that could affect you and your co-employees.
Obey safety signs and tags.
Always perform your assigned task in a safe and proper manner; do not take shortcuts. The taking of shortcuts and the ignoring of established safety rules is a leading cause of employee injury.
I certify that l have read and understand and will abide by the above listed safety rules. Failure to do so may be grounds for termination and may disqualify my insurance benefits. By signing this form, I agree to the following: I am responsible for the equipment or property issued to me including Hard Hats 30.00 and Lanyards (550.00); I will use it/them in the manner intended; I will be responsible for any damage done (excluding normal wear & tear); upon separation from the Company, I will return the item(s) issued to me in proper working order (excluding normal wear & tear); I will replace any items issued to me that are damaged or lost at my expense; I authorize a payroll deduction to cover the replacement cost of any item issued to me that is not returned for whatever reason, or is not returned in good working order.
We are equal opportunity employer and drug-free workplace.
You agree your electronic signature is the legal equivalent of your manual signature on this Application.
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Direct Deposit or ComData Pay Card
Direct Deposit Authorization
I hereby authorize Road Dog Industrial to initiate credit entries and to initiate, if necessary, debit entries and adjustments for any entries in error to my checking or savings account indicated above and the depository named above, to credit and/or
debit the same to such account. As a result of the complexities involved with electronic funds transfer, your direct deposit amount may not be reflected in your account for up to two (2) days after your company's pay date.
Comdata Pay Card
Please complete the following consent form to sign up for the Comdata Pay Card.
By signing below, I consent to receive my wages by electronic transfer to my Comdata card. I acknowledge I also understand and agree to the fees that I will incur using the Comdata card.
Please note that when selecting a pay card that the fee to overnight will be deducted from your first paycheck.
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Skip This Section and Waive All Insurance
You must either
ENROLL or WAIVE coverage. Go to www.psg.tsebenefits.com to make your benefit elections online. You may also complete this form and submit to Human Resources for a representative to enroll on your behalf. Please complete all fields. *SISCO will be the call center for any questions during your enrollment. Contact SISCO at 844-631-6104.
Upon missing one week of any health insurance payroll deduction, the next weeks payroll will have double payroll deductions (current deduction + missed deduction) to make up for the insurance premium(s) owed for the missed week. You are responsible to send a check or money order within 5 business days to: Personnel Staffing Group, 1751 Lake Cook Rd. Suite 600 Deerfield, IL 60015, Attention Benefits Team. If we do not receive payment within 10 business days of the missed payroll deduction, your benefits will be terminated due to non-payment back to the first date of missed premiums.
New for 2018 – Proof of eligibility for coverage is required for each dependent you enroll in a benefit plan. You can upload dependent verification documents to the enrollment portal or email copies to firstname.lastname@example.org. DO NOT send in originals documents.
Reason for Application
Your Personal Information
Enter dependent information for all dependents who will be covered on your insurance plans.
Medical Plan Options
Select your medical plan from the following options. Check the box on the right based on the plan and coverage category.
Check “waive” if you are waiving medical coverage. Your hourly pay rate will decide which Monthly/Weekly Rate and Tier below you belong to. Tier 1: $7.25—$7.99; Tier 2: $8.00—$8.99; Tier 3: $9.00—$9.99; Tier 4: $10.00 and higher
Medical Indemnity Plan Options
Check the box on the right to indicate the plan and coverage category OR check “waive” to decline coverage.
Check the “add” or “waive” box at the bottom of the chart to add or decline coverage.
Voluntary Dental Plan
Check the box on the right based on the coverage category. Check “waive” if you are waiving voluntary dental coverage.
Voluntary Vision Plan
Check the box on the right based on the coverage category. Check “waive” if you are waiving voluntary vision coverage.
Check the box on the right based on the coverage category. Check “waive” if you are waiving voluntary life coverage.
Provide primary and secondary (if applicable) beneficiary information for life insurance. Beneficiary percentage must equal 100%.
Secondary Beneficiaries (if applicable)
Voluntary Off-the‐Job Accident
Check the box on the right based on the coverage category. Check “waive” if you are waiving voluntary accident insurance.
Short Term Disability (STD)
Check the appropriate box on the right if you want to accept or waive short-term disability coverage.
Voluntary Critical Illness
Check the box on the right based on the coverage category. See weekly age‐based rates below for Tobacco vs. Non-Tobacco. Check “waive” if you are waiving voluntary critical illness insurance.
Weekly Age-Based Rates for Tobacco vs. Non-Tobacco
Employee, EE & Child
Employee, EE & Child
Critical Illness Election
I have reviewed the benefits offered and made my desired coverage selections (or waived coverage where applicable). I understand that the stated elections for my MEC Plus or MVP Medical, Dental, and Vision plans will be administered on a pre‐tax basis under Section 125 and that these elections are irrevocable until the next enrollment period or in the event of a Qualified Life Event. The MEC or Indemnity Medical plans will be administered on a after-tax basis. A waiver of coverage election is irrevocable until the next enrollment period.