Dear Applicant,

Thank you for your interest in McKesson Corporation.

Enclosed you will find eight (8) documents that make up the McKesson Employment Application.
For your employment information, 7 years of history are required. Please fill out each document
completely. P
application. We need the employer name and full address, phone number, dates of employment,
job title and salary for verification purposes. nclude any part-time employment or PRN positions
(for healthcare workers) held.
PIease pay cIose attention to the questions 4 & 5 on page 2. McKesson Corporation takes
the failure to disclose past convictions or pending charges very seriously. Please read the
instructions very carefully as to what you are required to disclose. The Company will not deny
employment to any applicant solely because the person has been convicted of a crime or has a
pending charge. The Company, however, may consider factors such as the nature and gravity of
the offense, time that has elapsed since the offense, the nature of the job, and the circumstances
surrounding the offense in making its hiring decision.
1. McKesson Corporation Application for Employment
2. Fair Credit Reporting Act (FCRA) form
3. Drug and Alcohol Testing Consent Form
4. Authorization for Release of Medical nformation complete only if applying for a position within
California
5. Licensure Verification form complete only if applying for positions that require licensure (i.e.
nurses, pharmacists, drivers). Please ask your recruiter if you are unsure.
6. EEO/Self-dentification form (voluntary)
7. Form 8850 (voluntary)
8. Summary of Rights under the FCRA for your information, does not need to be returned to
McKesson Corp.
Returning the EmpIoyment AppIication
720-239-4208, or you may scan and
return via email. Please mail the original to:
Kimberly White Mooney
11000 Westmoor Circle, Suite 125
Westminster, CO 80021
Thank you again for your interest. f you have any questions regarding these forms, please don't hesitate to
contact us.
Best regards,
McKesson Talent Acquisition Team
Application for Employment
McKesson Corporation and its subsidiaries and companies ("McKesson) are Equal Opportunity, Affirmative Action employers. No question on
this application or any of the attachments to this application is asked for the purpose of limiting or excluding any applicant's consideration for
employment because of race, color, religion, sex, sexual orientation, age, national origin, disability, veteran status, creed, marital status
citizenship, or any other category protected by law. You will be required to undergo pre-employment screening and drug testing, designed
to ascertain your suitability for employment for the job(s) for which you are being considered. Employment is contingent upon the results of such
screening and testing.
Please Print Legibly. Fill out Application Completely and Answer Every Question.
SociaI Security Number: ______________________________________ Date: __________________________________________
Name (print): First: ______________________________ MiddIe: _____________________ Last: ___________________________
Address: _____________________________ City: _________________________ State: ______________ Zip: _______________
County: _________________________ Home Phone: _________________________ Work Phone: _________________________
CeII Phone: ________________________ E-maiI Address: __________________________________________________________
Other First or Last Names which you have used which will help us locate employment, educational or court records:_______________________________________
Section A - PersonaI
Position applied for: ________________________ Full-time Part-time Date available for employment: __________________
Position location: _________________________ Shift: 1
st
2
nd
3
rd
Salary range desired: __________________________
How did you hear about employment with McKesson (be specific)? _____________________________________________________
f you were referred by a McKesson employee, please list the employee's name: ___________________________________________
Were you previously employed at McKesson? Yes No
f so, from __________ to ____________ Company Name: ______________________ Location: _________________________
Position/Department: ___________________ Your name at that time if different from present: _____________________________
Reason for leaving: ________________________________________________________________________________________
Are you related to anyone employed at McKesson? Yes No
f so, state your relative's name: __________________________ McKesson location: ____________________________________
Are you authorized to work in the United States indefinitely? Yes No
Are you a U.S. citizen or national, a lawful U.S. permanent resident, a refugee approved for entry to the U.S. or a person who has been
granted asylum in the U.S? Yes No
f the answer is No, what is your current immigration status in the U.S.? ______________________________________________
Will McKesson need to sponsor you for employment? Yes No
PIease note: A "Yes" answer to any of the foIIowing questions wiII not necessariIy disquaIify you from empIoyment.
1. Have you ever illegally sold any narcotics, amphetamines, barbiturates or other dangerous drugs? Yes No
f "Yes, give details: ______________________________________________________________________________________
2. Are you currently illegally using narcotics, amphetamines, barbiturates or other dangerous drugs? Yes No
f "Yes, give details: ______________________________________________________________________________________
3. ONLY ANSWER F APPLYNG FOR EMPLOYMENT N A DEA-LCENSED FACLTY (e.g., DRUG DSTRBUTON CENTER).
n the past three years, have you ever illegally used any narcotics, amphetamines, barbiturates or
other dangerous drugs? Yes No
f "Yes, give details: _____________________________________________________________________________________
PER-80 (R 7/08) Page 1 of 4
Empowering Healthcare
521-81-3725 6 December 2011
Micah Woodrow Phillips
10341 W 59th Ave #4 Arvada CO 80004
Jefferson County (303) 444-0120
(720) 712-8923 [email protected]
Woody
Product Support Rep

Now
Westminster, CO 34,000 +
Khrys Sganga sent me a notification about the job.
Khrys Sganga

APPLICATION FOR EMPLOYMENT

Name (Last, First):
4. For all applicants, except those in Hawaii (who should skip this question): Have you ever been convicted of any crime?
This includes any felony, misdemeanor and traffic convictions (excluding speeding & minor traffic violations), as well as current
deferred adjudication programs, probation before judgment convictions and nolo contendere pleas (do not include those that have been
sealed, expunged, erased, pardoned or statutorily eradicated). CaIifornia applicants: Do not include convictions for marijuana-related
offenses that are more than two years old or convictions that resulted in a diversion program including misdemeanors for which
probation was completed and the case dismissed. Washington applicants: Do not include convictions that are more than ten years old.
Massachusetts applicants: Do not include misdemeanors more than five years old or first offenses of drunkenness, simple assault,
speeding, minor traffic violations, affray, disturbance of the peace or anything pertaining to a juvenile record, unless tried as an adult in
Superior Court. An applicant for employment with a sealed record on file with the commissioner of probation may answer "no record
with respect to an inquiry herein relative to convictions. Yes No
f "Yes, complete the following (attach additional pages if necessary and indicate on line below to see attachment):
Criminal conviction(s): _______________________________________________________________________________________
Location(s): State: ___________________County: _________________________Court: ____________________________________
Date(s) and sentence(s): _______________________________________________________________________________________
5. Have you been arrested for any crime for which you are currently out on bail or on your own recognizance or which have not yet required
a court appearance (i.e., pending cases)? (Applicants in Hawaii and Rhode sland should skip this question) Yes No
f "Yes, please complete the following (attach additional pages if necessary):
Criminal charge(s): ___________________________________________________________________________________________
Location(s): State: ___________________County: _________________________Court: ____________________________________
Date(s): ____________________________________________________________________________________________________
The Company will not deny employment to any applicant solely because the person has been convicted of a crime. The Company, however, may consider factors
such as the nature, date, circumstances and the job-relatedness of the offense in its hiring decision.
Please start with your present or last position. nclude complete past work history, including full-time military
duty. Please complete even if this information is on your resume. f necessary, please attach an additional
sheet with other employment history that meets or exceeds the years of employment history required by the
McKesson business to which you are applying. With the exception of current employees, McKesson will verify
employment history with this employer upon a conditional offer of employment.
Section B - Work History
1. Company or organization name: ______________________________________________ Phone:_________________________
Address: ___________________________ City: __________________ State: ________ Zip: __________ Full-time Part-time
Department: ________________________ ndustry Type: ______________________ Employed from (mm/yy) ________ to ________
Salary at start: _________________________ Salary at leaving: ________________________ Bonus: _________________________
Title(s): _____________________________________________________________________________________________________
Duties performed: ____________________________________________________________________________________________
Name/Title of supervisor: __________________________________________________ Phone: ______________________________
Reason for leaving or considering change: _________________________________________________________________________
Are you currently employed by this company/organization? Yes No
f "Yes, may we contact your current employer upon a conditional offer of employment?
Yes No (f "No, we reserve the right to check after start of employment. f hired, your employment is contingent upon
the successful completion of such reference and background checks.)
2. Company or organization name: ______________________________________________ Phone:_________________________
Address: ___________________________ City: __________________ State: ________ Zip: __________ Full-time Part-time
Department: ________________________ ndustry Type: ______________________ Employed from (mm/yy) ________ to ________
Salary at start: _________________________ Salary at leaving: ________________________ Bonus: _________________________
Title(s): _____________________________________________________________________________________________________
Duties performed: ____________________________________________________________________________________________
Name/Title of supervisor: __________________________________________________ Phone: ______________________________
Reason for leaving or considering change: _________________________________________________________________________
Are you currently employed by this company/organization? Yes No
f "Yes, may we contact your current employer upon a conditional offer of employment?
Yes No (f "No, we reserve the right to check after start of employment. f hired, your employment is contingent upon
the successful completion of such reference and background checks.)
PER-80 (R 7/08) Page 2 of 4
Empowering Healthcare

PAR Technology Corp 303-444-0120

2511 55th Street Boulder CO 80301

Helpdesk T Support 04/09 12/11
28,000 30,000 -
CSCC Customer Engineer
Technical Assistance, some Shiftleading
Terance Slade (CSCC Floor Supervisor) (303) 444-0120
The prospect of more time at home

TEK Systems (888) 835-7978

8700 Turnpike Drive Westminster CO 80301

Temporary Consultant T Support 10/08 04/09

28,000 28,000 -
Associate Customer Engineer for PAR Technology nc
Technical Assistance, some Shiftleading
Beth Hayden (With PAR Tech) (303) 444-0120
Was hired on with PAR after being a temp there through TEK Systems.

APPLICATION FOR EMPLOYMENT

Name (Last, First):
3. Company or organization name: ______________________________________________ Phone:_________________________
Address: ____________________________ City: ___________________ State: _______ Zip: __________ Full-time Part-time
Department: ________________________ ndustry Type: ______________________ Employed from (mm/yy) ________ to ________
Salary at start: _________________________ Salary at leaving: ________________________ Bonus: _________________________
Title(s): _____________________________________________________________________________________________________
Duties performed: ____________________________________________________________________________________________
Name/Title of supervisor: __________________________________________________ Phone: ______________________________
Reason for leaving or considering change: _________________________________________________________________________
Are you currently employed by this company/organization? Yes No
f "Yes, may we contact your current employer upon a conditional offer of employment?
Yes No (f "No, we reserve the right to check after start of employment. f hired, your employment is contingent upon
the successful completion of such reference and background checks.)
4. Company or organization name: ______________________________________________ Phone:_________________________
Address: ___________________________ City: ___________________ State: _______ Zip: __________ Full time Part time
Department: ________________________ ndustry Type: ______________________ Employed from (mm/yy) ________ to ________
Salary at start: _________________________ Salary at leaving: ________________________ Bonus: _________________________
Title(s): _____________________________________________________________________________________________________
Duties performed: ____________________________________________________________________________________________
Name/Title of supervisor: __________________________________________________ Phone: ______________________________
Reason for leaving or considering change: _________________________________________________________________________
Are you currently employed by this company/organization? Yes No
f "Yes, may we contact your current employer upon a conditional offer of employment?
Yes No (f "No, we reserve the right to check after start of employment. f hired, your employment is contingent upon
the successful completion of such reference and background checks.)
Have you ever been terminated from any position other than a layoff or reduction in force or resigned by mutual agreement? Yes No
Company Name: ____________________________________________________________________________________________________
Please explain: _____________________________________________________________________________________________________
Section C - Education Please list educational institutions and degrees received. Complete this section even if this information is on your resume.
SchooI SchooI Name,
Location & Phone
Course of Study Degree, DipIoma or
Certificate Obtained
Date CompIeted
High SchooI/GED
(Indicate if GED)
CoIIege
TechnicaI/VocationaI
Other(s)
PER-80 (R 7/08) Page 3 of 4
Empowering Healthcare
Olive Garden (Darden Restaurants) (303) 650-0889
5581 W 88th Ave Westminster CO 80031

Serving Staff Food Handling / Waiting 09/07 10/08
< 20,000 20,000 -
Server
Waited Tables
(303) 650-0889
Better opportunity with PAR, closer to my chosen field

Pomona HS 303-982-0710
8101 West Pomona Drive Arvada
- Diploma
Westwood College 855-279-8228
7350 N Broadway, Denver, CO
BS - Game Software Dev Yes 05/08
APPLICATION FOR EMPLOYMENT
Name (Last, First):
Section D - Licensure (to be compIeted by registered, Iicensed or certified appIicants)
Type State Current Number Expiration Date
Driver's License Number State Expiration Date Type
CompIete onIy if appIying for position that requires the operation of a motor vehicIe.
Section E - Keyboard / Computer SkiIIs
What personaI computer software can you operate?
Proficiency LeveI
PLEASE READ CAREFULLY BEFORE SIGNING:
INVESTIGATION AND REPRESENTATIONS:
authorize investigation of all statements contained in this application and accompanying resume if any.
understand that any misrepresentation or omission of the facts called for will constitute sufficient reason to
terminate the application process or, if already employed, to terminate my employment. further certify that am
not currently on the Health and Human Services' Office of nspector General's (OG) Exclusion List nor am
currently on the U.S. General Services Administration's (GSA) Exclusion List and further certify that am not
currently on the Treasury Department's Office of Foreign Asset Control's Terrorism Exclusion List pursuant to
Executive Order 13224. give the employer the right to investigate all references and to secure additional job-
related information about me. hereby release McKesson and representatives from liability for seeking such
information and all other persons, corporations or organizations for furnishing such information. understand and
agree that McKesson, any agent acting on its behalf, as well as any other person responding to a reference
request pursuant to this application, can and will seek and/or disclose any and all lawful, job-related information
about me which said corporation, agent or person may have. specifically authorize said disclosure and agree to
hold all such corporations, agents or persons harmless for same. That is, will not file a lawsuit, claim or charge
against them for such disclosure. Nor will threaten same or otherwise seek any kind of compensation for such
disclosure.
understand and agree that McKesson maintains a drug-free workplace, that maintenance of a drug-free
workplace is essential to the safety of the workplace and employees, and that will be required to undergo pre-
employment screening and drug testing designed to ascertain my suitability for employment for the job(s) for
which am being considered. understand that, subject to applicable law, McKesson shall be the sole judge of
the acceptability of any test results. acknowledge that failure to complete drug screening within the timeframe
designated by McKesson may result in McKesson withdrawing its offer of employment. also acknowledge that
have been advised that McKesson is an Equal Opportunity, Affirmative Action employer.
understand that McKesson's smoking policy prohibits smoking in general working areas, customer areas,
McKesson vehicles, restrooms and within 50 feet of any building entrance, unless otherwise required by law.
understand that this policy applies to customers, vendors and guests, as well as applicants, contractors,
consultants, temporary employees and McKesson employees.
understand that, if am hired, both McKesson and have the right to terminate the employment relationship at
any time and for any lawful reason with or without cause. further understand that, although over the course of
my employment other terms and conditions of my employment may change, this term of my employment will not
change. understand that no one other than an expressly authorized officer of McKesson is empowered to make
any representation to me or enter into any agreement contrary to at-will employment, and that any contrary
agreement must be in writing and signed by such officer.
AT-WILL EMPLOYMENT:
InitiaI
InitiaI
InitiaI
InitiaI
Signature Date
Keyboard
Speed
PER-80 (R 7/08) Page 4 of 4
Empowering Healthcare
80 80 80
80
All Microsoft Products since Windows 3.1 including Office
Linus/Unix, FreeBSD, and MacOS X
Proficient
Proficient
DISCLOSURE
You are hereby notified that McKesson Corporation (the "Company) may procure a consumer report and/or an
investigative consumer report on you in connection with your employment application and/or your employment,
pursuant to the Fair Credit Reporting Act and similar state laws. HireRight, a consumer reporting agency, will
obtain the report for the Company. HireRight may be contacted at 800-400-2761 or 2100 Main Street, Suite 400
rvine, CA 92614.
The report may contain information bearing on your character, general reputation, personal characteristics, mode
of living and/or credit standing. The types of information that may be obtained include, but are not limited to:
credit reports, social security number verification, criminal records checks, public court records checks, driving
records checks, educational records checks, verification of employment positions held, personal and professional
references checks, licensing and certification checks, etc. The information contained in the report will be obtained
from private and/or public record sources, including sources identified by you in your job application or through
interviews or correspondence with your past or present coworkers, neighbors, friends, associates, current or
former employers, educational institutions or other acquaintances.
The nature and scope of any investigative consumer reports that may be requested is explained above.
Nevertheless, you are entitled to obtain more information about the nature and scope of such reports by
submitting a written request to: McKesson Human Resources, One Post Street San Francisco, CA 94104.
The Company is furnishing you with a summary of your rights under the Fair Credit Reporting Act in a form
prescribed by the Federal Trade Commission, which is attached.
Also, please review and sign the next page if you authorize a "background check to be conducted by HireRight
for McKesson Corporation.
AUTHORIZATION
have carefully read and understand the previous disclosure and this authorization form. By my signature below,
consent to the preparation and release of consumer and/or investigative consumer reports to the Company.
understand that my consent will remain valid in connection with my employment, if any, unless revoke it by
sending a signed letter to McKesson Human Resources, One Post Street San Francisco, CA 94104.
By my signature below, authorize the disclosure of information concerning my employment, earnings history,
education, credit history, credit capacity, credit standing, motor vehicle history, criminal history, and all other
information deemed pertinent by HireRight to McKesson Corp. from the following private and public sector
entities: past and present employers; learning institutions, including colleges and universities; law enforcement
agencies; federal, state and local courts; the military; credit bureaus; and, motor vehicle records agencies.
understand that, to the extent allowed by law, information contained in my job application or otherwise disclosed
to the Company by me, may be utilized for the purpose of obtaining consumer reports and/or investigative
consumer reports.
For positions Iocated in CaIifornia, Minnesota and OkIahoma: You will be provided with a free copy of any
consumer reports or investigative consumer reports if you check the box below. You may obtain information or
copies from the Company's investigative report file at any time prior to your receipt of such copies, to the extent
available, by contacting McKesson Human Resources, One Post Street San Francisco, CA 94104.
request a free copy of the report (available to applicants for positions in CA, MN and OK).
Last Name: ________________________________ First: _______________ Middle: __________
Present Address: ________________________________________________________________
City/State/Zip: __________________________________________________________________
McKesson Corporation: FCRA Form -1- Last revised: 05/08
Empowering Healthcare

Previous Addresses (for the past seven (7) years) - attach additional sheets if necessary:
______________________________________________________________________________
From: __________ To: __________
Social Security Number:___________________________________
Driver's License/Other dentification Number: ________________
FOR IDENTIFICATION PURPOSES ONLY: Month and Day of Birth: _____________
_______________________________ ________________
Signature Date
From: __________ To: __________
______________________________________________________________________________
From: __________ To: __________
______________________________________________________________________________
ADDITIONAL STATE LAW NOTICES
f you are seeking employment in California, Maine or New York, please review these additional notices, and
initial where appropriate.
CALFORNA: You may view the file maintained on you by HireRight. You may also obtain a copy of this file,
upon submitting proper identification and paying the costs of duplication services, by appearing at HireRight
offices in person, during normal business hours and on reasonable notice, or by mail; you may also receive a
summary of the file by telephone. HireRight has trained personnel available to explain your file to you, including
any coded information. f you appear in person, you may be accompanied by one other person, provided that
person furnishes proper identification.
____ initial
MANE: You have the right, upon request, to be informed of whether a consumer report was requested, and if
one was requested, the name and address of the consumer reporting agency furnishing the report. You may
request and receive from the Company, within five business days of our receipt of your request, the name,
address and telephone number of the nearest unit designated to handle inquiries for the consumer reporting
agency issuing an investigative consumer report concerning you. You also have the right, under Maine law, to
request and promptly receive from all such consumer reporting agencies copies of any such investigative
consumer reports.
____ initial
NEW YORK: You have the right, upon written request, to be informed of whether or not an investigative
consumer report was requested. f an investigative consumer report is requested, you will be provided with the
name and address of the consumer reporting agency furnishing the report. You may inspect and receive a copy of
the report by contacting that agency.
____ initial
McKesson Corporation: FCRA Form -2- Last revised: 05/08
521-81-3725
02-225-0600
Jan 16
DRUG AND ALCOHOL TESTING CONSENT FORM
Name: _____________________________ Location: ____________________
hereby consent and agree to drug and/or alcohol testing as a condition of consideration for employment
and/or continued employment by McKesson Corporation, nc.
understand that information regarding my test results will be released to McKesson and that such
information may be used as grounds for adverse employment action, including a withdrawal of any
conditional offer of employment, or termination of my employment with McKesson.
further understand and acknowledge that:
a. McKesson will pay the costs of all drug and/or alcohol tests required or requested by McKesson;
b. will be provided with a copy of the results of any non-negative test;
c. f my test specimen is confirmed as positive, will be contacted by a Medical Review Officer, and
offered the opportunity to provide information that may explain the test result, and to request a
confirmatory retest, at my own expense, of my original test specimen; and
d. have the right to refuse to submit to such testing; however, refusal by me to submit to or to
cooperate (including by adulterating, substituting, or diluting test specimens) will be considered a
voluntary withdrawal of my employment application or, if am an employee, a violation of McKesson's
Substance Abuse Prevention Policy which may result in my immediate discharge from employment.
With full knowledge of the foregoing, hereby agree to submit to drug testing requested by McKesson.
have read the above consent to drug and/or alcohol testing and certify that have signed this document
of my own free will and accord, fully understand the contents of this document, and stipulate that my
consent is knowing and voluntary. also understand that this consent form does not alter McKesson's
policy that employment is terminable at-will, at the option of either McKesson or me. also acknowledge
that, where required by state law, have received a copy of the McKesson Substance Abuse Prevention
Policy and have had the opportunity to review the policy and ask questions about it.
____________________________________ _____________________________
Applicant/Employee Signature Date
____________________________________
Applicant/Employee Printed Name
McKesson Corporation: Drug Testing Consent -1- Last revised: 05/06
Empowering Healthcare
AUTHORIZATION FOR
RELEASE OF MEDICAL INFORMATION
(CaIifornia onIy)
, ______________________, hereby authorize
__________________________ laboratory to release to McKesson
Corporation ("the Company) and its designated agents, including its
testing administrator, HireRight, its Medical Review Officers, and
Substance Abuse Professionals, the results of the laboratory tests to which
have consented for the purpose of determining the presence of drugs
and/or alcohol in my body. expressly understand and agree that the
Company will review the results of these tests in connection with making a
decision concerning my employment. Other than for the purpose of making
a determination concerning my employment, understand that the
Company will not use or further disclose the information released pursuant
to this authorization unless further expressly authorized by me or unless
disclosure is required by law.
This authorization shall become effective immediately and remain in
effect until 90 days from the date below. understand that have the right
to receive a copy of this authorization upon request.
Date Signature
Printed Name
McKesson Model CA Medical Release -1- Last revised: 05/06
Empowering Healthcare
LICENSURE VERIFICATION FORM
**PLEASE COMPLETE AND RETURN WITH APPLICATION FORM**
Name:
(Please Print)
Social Security Number:
State oI Residence: State(s) Applying Eor:
PLEASE LIST THE STATE(S) IN WHICH YOU ARE CURRENTLY LICENSED.
YOU ARE REQUIRED TO DISCLOSE ANY PENDING ACTION AGAINST YOUR LICENSES. PLEASE EXPLAIN BELOW.
State License # Expires Actions pending against this
license? Yes/No
State License # Expires Actions pending against this
license? Yes/No
State License # Expires Actions pending against this
license? Yes/No
State License # Expires Actions pending against this
license? Yes/No
State License # Expires Actions pending against this
license? Yes/No
State License # Expires Actions pending against this
license? Yes/No
DETAILS OE PENDING ACTION AGAINST LICENSE:
*If you are hired, you will be required to provide a copy of all your current licenses*
Signature: Date:
Pre-employment License VeriIication Eorm
Empowering Healthcare
Voluntary Information for Government Reporting Purposes
EEO/Self-Identication Information
(Completion of this form is voluntary)
Date
Last Name (Print)
Street Address
Signature
McKesson Corporation (Company) provides equal opportunity Ior all qualifed applicants and employees, without regard to race, color, religion,
sex, national origin, age, disability, veteran status, gender identity, political preIerence, sexual orientation, marital status, citizenship, or other status
protected by law or regulation. The Company prohibits discrimination in any aspect oI employment, including hiring, promotion, demotion,
transIer, layoII or termination, rates oI pay, or selection Ior training. The Company also undertakes aIfrmative action programs to Iacilitate Iull and
equal participation oI all employees in the opportunities available within McKesson.
The Company is subject to certain governmental recordkeeping and reporting requirements Ior the administration oI civil rights laws and
regulations. In order to comply with these laws, the Company invites employees to voluntarily selI-identiIy their race/ethnicity and gender. Your
response will Iacilitate the Company`s equal employment opportunity eIIorts and assure that Company records refect accurate inIormation.
Submission oI this inIormation is voluntary and reIusal to provide it will not subject you to adverse treatment. Employment decisions will not be
based on whether or not you provide the inIormation, and this inIormation will not become part oI your applicant fle. The inIormation will be kept
confdential and will only be used in accordance with the provisions oI applicable laws, executive orders, and regulations, including those that
require the inIormation to be summarized and reported to the Iederal government Ior civil rights enIorcement. Where reported, data will not
identiIy any specifc individual. (See defnitions below Ior assistance.)
Ethnic Identication
Eirst
City and State
Social Security Number
Middle
Zip Code
Position Applying Eor
Gender:
Male
Eemale
I choose not to identiIy
Hispanic or Latino
White
Black or AIrican American
Asian
Native Hawaiian or Pacifc Islander
American Indian or Alaska Native
Two or More Races
I choose not to identiIy
What is your race/ ethnicity? From the proposed
eight categories, please select only one response.
Hispanic or Latino
White
Black or AIrican American
Asian
Native Hawaiian or Pacifc Islander
American Indian or Alaska Native
I choose not to identiIy
If you have selected the ~Two or More Races
category, select all of the categories, in which you
identify, from the list below.
Hispanic or Latino
White
Persons oI Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or
origin, regardless oI race.
Black or AIrican American
Asian
Native Hawaiian or Other Pacifc
Islander
American Indian or Alaskan Native
Two or More Races
Persons having origins in any oI the original peoples oI Europe, the Middle East, or North AIrica.
Persons having origins in any oI the black racial groups oI AIrica.
Persons having origins in any oI the peoples oI Hawaii, Guam, Samoa, or other Pacifc Islands.
Persons having origins in any oI the original peoples oI the Ear East, Southeast Asia, or the Indian
subcontinent, including, Ior example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the
Philippine Islands, Thailand, and Vietnam.
Persons having origins in any oI the original peoples oI North and South America (including Central
America), and who maintain tribal aIfliation or community attachment.
All persons who identiIy with more than one oI the above fve races.
Race/Ethnicity Categories Denition
Empowering Healthcare

OMB No. 1545-1500
Form
Department of the Treasury
lnternal Revenue Service

Check here if you received a conditional certification from the state workforce agency (SWAj or a participating local agency
for the work opportunity credit.

l am a member of a family that has received assistance from Temporary Assistance for Needy Families (TANFj for any
9 months during the past 18 months.

Cat. No. 22851L

Form (Rev. 8-2009j

(Rev. August 2009j


Your name

Street address where you live

City or town, state, and ZlP code

Received SNAP benefits (food stampsj for the past 6 months,


w

lf you are under age 40, enter your date of birth (month, day, yearj

Social security number
w

/ /

l am a veteran and a member of a family that received Supplemental Nutrition Assistance Program (SNAPj benefits
(food stampsj for at least a 3-month period during the past 15 months.

l was referred here by a rehabilitation agency approved by the state, an employment network under the Ticket to Work
program, or the Department of veterans Affairs.

l am at least age 18 but age 40 or older and l am a member of a family that:

During the past year, l was convicted of a felony or released from prison for a felony.

Received SNAP benefits (food stampsj for at least 3 of the past 5 months, is no longer eligible to receive them.

Under penalties of perjury, l declare that l gave the above information to the employer on or before the day l was offered a job, and it is, to the best of my
knowledge, true, correct, and complete.

/ /



County

w


Check here if of the following statements apply to you.

Check here if you are a member of a family that:

Received TANF payments for at least the past 18 months,

Stopped being eligible for TANF payments during the past 2 years because federal or state law limited the maximum
time those payments could be made.

l received supplemental security income (SSlj benefits for any month ending during the past 60 days.

Check here if you are completing this form August 28, 2009, and you lived in the area impacted by Hurricane Katrina
on August 28, 2005. lf so, please enter the address, including county or parish and state where you lived at that time.

Received TANF payments for any 18 months beginning after August 5, 1997, the earliest 18-month period beginning
after August 5, 1997, ended during the past 2 years,

Check here if you are a veteran entitled to compensation for a service-connected disability during the past year,
you were:

Discharged or released from active duty in the U.S. Armed Forces,

Unemployed for a period or periods totaling at least 6 months.

Telephone number

( j -

l am a veteran and l was discharged or released from active duty in the U.S. Armed Forces during the past 5 years
for at least 4 weeks during the past year, l received unemployment compensation.

l am at least age 16 but age 25 or older,

During the past 6 months, l have not attended a secondary, technical, or post-secondary school for more than
an average of 10 hours per week, not counting periods during which the school was closed for scheduled
vacations,



During the past 6 months, if l was employed, during each consecutive 3-month period within the past 6 months,
l earned less than l would have earned if l had worked for the applicable minimum wage 30 hours every week
during the 3-month period,

l do not have a certificate of graduation from a secondary school or a General Education Development (GEDj
certificate l have a certificate that was awarded at least 6 months ago and l have not held a job (other than
occasionallyj or been admitted to a technical or post-secondary school since l received the certificate.

Micah Woodrow PhiIIips 521 81 3725
10341 W 59th Ave #4
Arvada, CO 80004
Jefferson County 720 412 8923
01 16 1987
Page

Form 8850 (Rev. 8-2009j


Employer's name

City or town, state, and ZlP code

Date applicant:

Telephone no.
Street address

Under penalties of perjury, l declare that the applicant provided the information on this form on or before the day a job was offered to the applicant and
that the information l have furnished is, to the best of my knowledge, true, correct, and complete. Based on the information the job applicant furnished on
page 1, l believe the individual is a member of a targeted group. l hereby request a certification that the individual is a member of a targeted group.

Gave
information

Was
offered job

Was
hired

Started
job


w

/ /

/ /

/ /

/ /

/ /

ElN
w

lf, based on the individual's age and home address, he or she is a member of group 4 or 6 (as described under Members
of Targeted Groups in the separate instructionsj, enter that group number (4 or 6j
w

( j -

Person to contact, if different from above

City or town, state, and ZlP code

Telephone no.

Street address

( j -





Section 51(dj(13j permits a prospective
employer to request the applicant to
complete this form and give it to the
prospective employer. The information
will be used by the employer to
complete the employer's federal tax
return. Completion of this form is
voluntary and may assist members of
targeted groups in securing employment.
Routine uses of this form include giving
it to the state workforce agency (SWAj,
which will contact appropriate sources
to confirm that the applicant is a
member of a targeted group. This form
may also be given to the lnternal
Revenue Service for administration of
the lnternal Revenue laws, to the
Department of Justice for civil and

The time needed to complete and file
this form will vary depending on
individual circumstances. The estimated
average time is:

3 hrs., 16 min.


46 min.


42 min.

lf you have comments concerning the
accuracy of these time estimates or
suggestions for making this form
simpler, we would be happy to hear
from you. You can write to the lnternal
Revenue Service, Tax Products
Coordinating Committee,
SE:W:CAR:MP:T:T:SP, 1111 Constitution
Ave. NW, lR-6526, Washington, DC
20224.

Do not send this form to this address.
lnstead, see in
the separate instructions.




Form (Rev. 8-2009j

criminal litigation, to the Department of
Labor for oversight of the certifications
performed by the SWA, and to cities,
states, and the District of Columbia for
use in administering their tax laws. 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.

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 lnternal Revenue
law. Generally, tax returns and return
information are confidential, as required
by section 6103.

State and
county or
parish of job

Check if the individual was not your employee
on August 28, 2005, and this is the first time
the employee has been hired by you since
August 28, 2005.



A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT
The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of
information in the files of consumer reporting agencies. There are many types of consumer reporting
agencies, including credit bureaus and specialty agencies (such as agencies that sell information about
check writing histories, medical records, and rental history records). Here is a summary of your major
rights under the FCRA. For more information, including information about additional rights, go to
www.ftcgov/credit or write to: Consumer Response Center, Room 130-A, Federal Trade
Commission, 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.
You must be toId if information in your fiIe has been used against you. Anyone who uses a
credit report or another type of consumer report to deny your application for credit, insurance, or
employment or to take another adverse action against you must tell you, and must give you the
You have the right to know what is in your fiIe. You may request and obtain all the information
about you in the files of a consumer reporting agency (your "file disclosure). You will be required to
provide proper identification, which may include your Social Security number. n many cases, the
You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-
worthiness based on information from credit bureaus. You may request a credit score from consumer
reporting agencies that create scores or distribute scores used in residential real property loans, but
you will have to pay for it. n some mortgage transactions, you will receive credit score information for
free from the mortgage lender.
You have the right to dispute incompIete or inaccurate information. f you identify information in
your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency
must investigate unless your dispute is frivolous. See www.ftc.gov/credit for an explanation of dispute
procedures.
Consumer reporting agencies must correct or deIete inaccurate, incompIete, or unverifiabIe
information. naccurate, incomplete or unverifiable information must be removed or corrected,
usually within 30 days. However, a consumer agency may continue to report information it has
verified as accurate.
Consumer reporting agencies may not report outdated negative information. n most cases, a
consumer reporting agency may not report negative information that is more than seven years old, or
bankruptcies that are more than 10 years old.
Access to your fiIe is Iimited. A consumer reporting agency may provide information about you
only to people with a valid need usually to consider an application with a creditor, insurer, employer,
landlord, or other business. The FCRA specifies those with a valid need for access.
name, address, and phone number of the agency that provided the information.
disclosure will be free. You are entitled to a free file disclosure if:
n addition, all consumers are entitled to one free disclosure every 12 months upon request from each
nationwide credit bureau and from nationwide specialty consumer reporting agencies. See
www.ftc.gov/credit for additional information.
a person has taken adverse action against you because of information in your credit report;
you are the victim of identity theft and place a fraud alert in your file;
your file contains inaccurate information as a result of fraud;
you are on public assistance;
you are unemployed but expect to apply for employment within 60 days.
McKesson Summary of Rights Under FCRA -1- Last revised: 05/06

You must give your consent for reports to be provided to empIoyers. A consumer reporting
agency may not give out information about you to your employer, or a potential employer, without
your written consent given to the employer. Written consent generally is not required in the trucking
industry. For more information, go to www.ftc.gov/credit.
You may Iimit "prescreened" offers of credit and insurance you get based on information in
your credit report. Unsolicited "prescreened offers for credit and insurance must include a toll-free
phone number you can call if you choose to remove your name and address from the lists these
offers are based on. You may opt-out with the nationwide credit bureaus at 1-888-5-OPTOUT (1-
888-567-8688).
You may seek damages from vioIators. f a consumer reporting agency, or, in some cases, a user
of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA,
you may be able to sue in state or federal court.
Identity theft victims and active duty miIitary personneI have additionaI rights. For more
information, visit www.ftc.gov/credit.
States may enforce the FCRA, and many states have their own consumer reporting Iaws. In some
cases, you may have more rights under state Iaw. For more information, contact your state or
IocaI consumer protection agency or your state Attorney GeneraI. FederaI enforcers are:
TYPE OF BUSINESS:
Consumer reporting agencies, creditors and others
not listed below
National banks, federal branches/agencies of
foreign banks (word "National or initials "N.A.
appear in or after bank's name)
Federal Reserve System member banks (except
national banks, and federal branches/agencies of
foreign banks)
Savings associations and federally chartered
savings banks (word "Federal or initials "F.S.B.
appear in federal institution's name)
Federal credit unions (words "Federal Credit Union
appear in institution's name)
State-chartered banks that are not members of the
Federal Reserve System
Air, surface, or rail common carriers regulated by
former Civil Aeronautics Board or nterstate
Commerce Commission
Activities subject to the Packers and Stockyards Act,
1921
PLEASE CONTACT:
Federal Trade Commission: Consumer Response
Center FCRA
Washington, DC 20580 1-877-382-4357
Office of the Comptroller of the Currency
Compliance Management, Mail Stop 6-6
Washington, DC 20219 800-613-6743
Federal Reserve Board
Division of Consumer & Community Affairs
Washington, DC 20551 202-452-3693
Office of Thrift Supervision
Consumer Complaints
Washington, DC 20552 800-842-6929
National Credit Union Administration
1775 Duke Street
Alexandria, VA 22314 703-519-4600
Department of Transportation, Office of Financial
Management
Washington, DC 20590 202-366-1306
Department of Agriculture
Office of Deputy Administrator- GPSA
Washington, DC 20250 202-720-7051
Federal Deposit nsurance Corporation
Consumer Response Center
2345 Grand Avenue, Suite 100
Kansas City, Missouri 64108-2638
1-877-275-3342
Firmwide:80893167.1 037360.1000
McKesson Summary of Rights Under FCRA -2- Last revised: 05/06