Exhibit E - Form NJ AA302 - Certificate of Employee Information Report (CEIR).pdf

Form AA302 Rev. 11/11

STATE OF NEW JERSEY

Division of Purchase & Property Contract Compliance Audit Unit

EEO Monitoring Program

EMPLOYEE INFORMATION REPORT

IMPORTANT-READ INSTRUCTIONS CAREFULLY BEFORE COMPLETING FORM. FAILURE TO PROPERLY COMPLETE THE ENTIRE FORM AND TO SUBMIT THE REQUIRED $150.00 FEE MAY DELAY ISSUANCE OF YOUR CERTIFICATE. DO NOT SUBMIT EEO-1 REPORT FOR SECTION B, ITEM 11. For Instructions on completing the form, go to:

https://www.state.nj.us/treasury/contract_compliance/documents/pdf/forms/aa302ins.pdf

SECTION A - COMPANY IDENTIFICATION

1. FID. NO. OR SOCIAL SECURITY 2. TYPE OF BUSINESS 3. TOTAL NO. EMPLOYEES IN THE ENTIRE

1. MFG 2. SERVICE 3. WHOLESALE COMPANY

4. RETAIL 5. OTHER

4. COMPANY NAME

5. STREET CITY COUNTY STATE ZIP CODE

6. NAME OF PARENT OR AFFILIATED COMPANY (IF NONE, SO INDICATE) CITY STATE ZIP CODE

7. CHECK ONE: IS THE COMPANY: SINGLE-ESTABLISHMENT EMPLOYER MULTI-ESTABLISHMENT EMPLOYER

8. IF MULTI-ESTABLISHMENT EMPLOYER, STATE THE NUMBER OF ESTABLISHMENTS IN NJ

9. TOTAL NUMBER OF EMPLOYEES AT ESTABLISHMENT WHICH HAS BEEN AWARDED THE CONTRACT

10. PUBLIC AGENCY AWARDING CONTRACT

CITY COUNTY STATE ZIP CODE

Official Use Only DATE RECEIVED INAUG.DATE ASSIGNED CERTIFICATION NUMBER

SECTION B - EMPLOYMENT DATA

11. Report all permanent, temporary and part-time employees ON YOUR OWN PAYROLL. Enter the appropriate figures on all lines and in all columns. Where there are no employees in a particular category, enter a zero. Include ALL employees, not just those in minority/non-minority categories, in columns 1, 2, & 3. DO NOT SUBMIT

AN EEO-1 REPORT.

ALL EMPLOYEES PERMANENT MINORITY/NON-MINORITY EMPLOYEE BREAKDOWN

JOB COL. 1 COL. 2 COL. 3 ********* MALE************************************FEMALE**********************

CATEGORIES TOTAL MALE FEMALE AMER. NON AMER. NON

(Cols.2 &3) BLACK HISPANIC INDIAN ASIAN MIN. BLACK HISPANIC INDIAN ASIAN MIN.

Officials/ Managers

Professionals

Technicians

Sales Workers

Office & Clerical

Craftworkers (Skilled)

Operatives (Semi-skilled)

Laborers (Unskilled)

Service Workers

TOTAL

Total employment From previous Report (if any) Temporary & Part- Time Employees

12. HOW WAS INFORMATION AS TO RACE OR ETHNIC GROUP IN SECTION B OBTAINED? 14. IS THIS THE FIRST 15. IF NO, DATE LAST

1. Visual Survey 2. Employment Record 3. Other (Specify) Employee Information REPORT SUBMITTED

Report Submitted?

13. DATES OF PAYROLL PERIOD USED

From: To: 1. YES 2. NO

MO. DAY YEAR

SECTION C - SIGNATURE AND IDENTIFICATION

16. NAME OF PERSON COMPLETING FORM (Print or Type) SIGNATURE TITLE DATE

MO DAY YEAR

17. ADDRESS NO. & STREET CITY COUNTY STATE ZIP CODE PHONE (AREA CODE, NO.,EXTENSION)

The data below shall NOT be included in the figures for the appropriate categories above.

https://www.state.nj.us/treasury/contract_compliance/documents/pdf/forms/aa302ins.pdf

INSTRUCTIONS FOR COMPLETING THE

EMPLOYEE INFORMATION REPORT (FORM AA302)

IMPORTANT: READ THE FOLLOWING INSTRUCTIONS CAREFULLY BEFORE COMPLETING THE FORM.

PRINT OR TYPE ALL INFORMATION. FAILURE TO PROPERLY COMPLETE THE ENTIRE FORM AND TO SUBMIT THE REQUIRED $150.00 NON-REFUNDABLE FEE MAY DELAY ISSUANCE OF YOUR CERTIFICATE. IF YOU HAVE A CURRENT CERTIFICATE OF EMPLOYEE INFORMATION REPORT, DO NOT COMPLETE THIS FORM UNLESS YOUR ARE RENEWING A CERTIFICATE THAT IS DUE FOR EXPIRATION. DO NOT COMPLETE

THIS FORM FOR CONSTRUCTION CONTRACT AWARDS.

ITEM 1 - Enter the Federal Identification Number assigned by the Internal Revenue Service, or if a Federal Employer Identification Number has been applied for, or if your business is such that you have not or will not receive a Federal Employer Identification Number, enter the Social Security Number of the owner or of one partner, in the case of a partnership.

ITEM 2 - Check the box appropriate to your TYPE OF BUSINESS. If you are engaged in more than one type of business check the predominate one. If you are a manufacturer deriving more than 50% of your receipts from your own retail outlets, check “Retail”.

ITEM 3 - Enter the total “number” of employees in the entire company, including part-time employees. This number shall include all facilities in the entire firm or corporation.

ITEM 4 - Enter the name by which the company is identified.

If there is more than one company name, enter the predominate one.

ITEM 5 - Enter the physical location of the company. Include City, County, State and Zip Code.

ITEM 6 - Enter the name of any parent or affiliated company including the City, County, State and Zip Code. If there is none, so indicate by entering “None” or N/A.

ITEM 7 - Check the box appropriate to your type of company establishment. “Single-establishment Employer” shall include an employer whose business is conducted at only one physical location. “Multi-establishment Employer” shall include an employer whose business is conducted at more than one location.

ITEM 8 - If “Multi-establishment” was entered in item 8, enter the number of establishments within the State of New Jersey.

ITEM 9 - Enter the total number of employees at the establishment being awarded the contract.

ITEM 10 - Enter the name of the Public Agency awarding the contract. Include City, County, State and Zip Code. This is not applicable if you are renewing a current Certificate.

ITEM 11 - Enter the appropriate figures on all lines and in all columns. THIS SHALL ONLY INCLUDE EMPLOYMENT

DATA FROM THE FACILITY THAT IS BEING AWARDED

THE CONTRACT. DO NOT list the same employee in more than one job category. DO NOT attach an EEO-1 Report.

Racial/Ethnic Groups will be defined:

Black: Not of Hispanic origin. Persons having origin in any of the Black racial groups of Africa.

Hispanic: Persons of Mexican, Puerto Rican, Cuban, or Central or South American or other Spanish culture or origin, regardless of race.

American Indian or Alaskan Native: Persons having origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition.

Asian or Pacific Islander: Persons having origin in any of the original peoples of the Far East, Southeast Asia, the Indian Sub-continent or the Pacific Islands. This area includes for example, China, Japan, Korea, the Phillippine Islands and Samoa.

Non-Minority: Any Persons not identified in any of the aforementioned Racial/Ethnic Groups.

ITEM 12 - Check the appropriate box. If the race or ethnic group information was not obtained by 1 or 2, specify by what other means this was done in 3.

ITEM 13 - Enter the dates of the payroll period used to prepare the employment data presented in Item 12.

ITEM 14 - If this is the first time an Employee Information Report has been submitted for this company, check block “Yes”.

ITEM 15 - If the answer to Item 14 is “No”, enter the date when the last Employee Information Report was submitted by this company.

ITEM 16 - Print or type the name of the person completing the form. Include the signature, title and date.

ITEM 17 - Enter the physical location where the form is being completed. Include City, State, Zip Code and Phone Number.

TYPE OR PRINT IN SHARP BALL POINT PEN

THE VENDOR IS TO COMPLETE THE EMPLOYEE INFORMATION REPORT FORM (AA302) AND RETAIN A COPY FOR THE VENDOR’S OWN FILES. THE VENDOR SHOULD ALSO SUBMIT A COPY TO THE PUBLIC AGENCY AWARDING THE CONTRACT IF THIS IS YOUR FIRST REPORT; AND FORWARD ONE COPY WITH A CHECK IN THE AMOUNT OF $150.00 PAYABLE TO

THE TREASURER, STATE OF NEW JERSEY(FEE IS NON-REFUNDABLE) TO:

NJ Department of the Treasury Division of Purchase & Property Contract Compliance Audit Unit

EEO Monitoring Program P.O. Box 206

Trenton, New Jersey 08625-0206 Telephone No. (609) 292-5473

Form AA- 302 Treasury D:20000727094525- 04'00' D:20000727094709- 04'00' Form AA302 Rev. 11/11

STATE OF NEW JERSEY

Division of Purchase & Property Contract Compliance Audit Unit EEO Monitoring Program

EMPLOYEE INFORMATION REPORT

IMPORTANT-READ INSTRUCTIONS CAREFULLY BEFORE COMPLETING FORM. FAILURE TO PROPERLY COMPLETE THE ENTIRE FORM AND TO SUBMIT THE REQUIRED $150.00 FEE MAY DELAY ISSUANCE OF YOUR CERTIFICATE. DO NOT SUBMIT EEO-1 REPORT FOR SECTION B, ITEM 11. For Instructions on completing the form, go to: https://www.state.nj.us/treasury/contract_compliance/documents/pdf/forms/aa302ins.pdf

SECTION A - COMPANY IDENTIFICATION

1. FID. NO. OR SOCIAL SECURITY

2. TYPE OF BUSINESS

3. TOTAL NO. EMPLOYEES IN THE ENTIRE

1. MFG

2. SERVICE

3. WHOLESALE

COMPANY

4. RETAIL 5. OTHER

4. COMPANY NAME

5. STREET

CITY

COUNTY

STATE

ZIP CODE

6. NAME OF PARENT OR AFFILIATED COMPANY (IF NONE, SO INDICATE)

CITY

STATE

ZIP CODE

7. CHECK ONE: IS THE COMPANY:

SINGLE-ESTABLISHMENT EMPLOYER

MULTI-ESTABLISHMENT EMPLOYER

8. IF MULTI-ESTABLISHMENT EMPLOYER, STATE THE NUMBER OF ESTABLISHMENTS IN NJ

9. TOTAL NUMBER OF EMPLOYEES AT ESTABLISHMENT WHICH HAS BEEN AWARDED THE CONTRACT

10. PUBLIC AGENCY AWARDING CONTRACT

CITY

COUNTY

STATE

ZIP CODE

Official Use Only

DATE RECEIVED

INAUG.DATE

ASSIGNED CERTIFICATION NUMBER

SECTION B - EMPLOYMENT DATA

11. Report all permanent, temporary and part-time employees ON YOUR OWN PAYROLL. Enter the appropriate figures on all lines and in all columns. Where there areno employees in a particular category, enter a zero. Include ALL employees, not just those in minority/non-minority categories, in columns 1, 2, & 3. DO NOT SUBMIT

AN EEO-1 REPORT.

ALL EMPLOYEES

PERMANENT MINORITY/NON-MINORITY EMPLOYEE BREAKDOWN

JOB COL. 1

COL. 2 COL. 3 ********* MALE************************************FEMALE**********************

CATEGORIES TOTAL MALE FEMALE

AMER.

NON

AMER. NON

(Cols.2 &3)

BLACK HISPANIC INDIAN ASIAN MIN. BLACK HISPANIC INDIAN ASIAN MIN.

Officials/ Managers Professionals Technicians Sales Workers Office & Clerical Craftworkers (Skilled) Operatives (Semi-skilled) Laborers (Unskilled) Service Workers

TOTAL

Total employment From previous Report (if any) Temporary & Part- Time Employees

12. HOW WAS INFORMATION AS TO RACE OR ETHNIC GROUP IN SECTION B OBTAINED? 14. IS THIS THE FIRST

15. IF NO, DATE LAST

1. Visual Survey 2. Employment Record 3. Other (Specify) Employee Information

REPORT SUBMITTED

Report Submitted?

13. DATES OF PAYROLL PERIOD USED

From:

To:

1. YES

2. NO

MO. DAY YEAR

SECTION C - SIGNATURE AND IDENTIFICATION

16. NAME OF PERSON COMPLETING FORM (Print or Type)

SIGNATURE

TITLE

DATE

MO DAY YEAR

17. ADDRESS NO. & STREET

CITY

COUNTY

STATE

ZIP CODE PHONE (AREA CODE, NO.,EXTENSION)

The data below shall NOT be included in the figures for the appropriate categories above.