APPLICATION FOR EMPLOYMENT

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APPLICATION FOR EMPLOYMENT

All fields marked with * are required. (Please Print)

Personal Information

*Name:

*Last *First * Middle Name or No Middle Name

*Contact Information:

*Home Telephone: Cell Telephone *E-Mail Address

Current Address

(Please provide all addresses where you have lived in the past 7 years)

*Current Address

*Street *City/State/Province *Zip/Postal Code

Previous Address

(

Note if you choose not to provide any address history, the company may not be able to evaluate your fit for the position(s) for which you are applying.) I do not have any previous address history.

*Previous Address

*Street *Street *City/State/Province *City/State/Province *Zip/Postal Code *Zip/Postal Code

Do you have additional addresses?

Yes No

Availability

*Available Start Date::

*Schedule:

Full Time

Part Time

*Times Available:

Any

Weekdays

Weekends

Evenings

Shift

Available to work overtime

*If hired, do you have reliable transportation to get to work?

Yes

No

General Questions

*How did you hear about us?

Did someone from this company refer you to us?

Yes

No

If yes, please provide their name:

*Do you have any relatives working for the Company?

(or its subsidiaries)

Yes

No

*If yes, please provide their name and relationship(s):

*Are you at least 18 years of age?

Yes

No

*Are you legally eligible to work in the United States?

Yes

No

(Proof of employment eligibility will be required, if hired.)

Will you now or in the future require this company to submit paperwork to the government to obtain work authorization for you (i.e. obtain an H-1B or

other employment work authorization)?

Yes

No

*Have your ever been terminated or been asked to resign from a job?

Yes

No

If yes, please provide the related details:

Education

*School (Include Name & Address)

*High School:

College/University:

Vocational/Business:

No. of Years Completed Degree or Diploma Did you Graduate?

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Employment History

(Please provide all current and/or previous employment references for the last ten (10) years, including gaps of employment.)

I do not have any employment history. (Note: if you choose not to provide any employment history, the company may not be able to evaluate your fit for the position(s) for which you are applying.)

*Name of Employer:

Address:

Street

Telephone Number:

City/State/Province Zip/Postal Code

Your Supervisor’s Name:

*Date of Employment:

*Starting Title:

*Starting Pay:

From:

(*List Month & Year)

To:

Current Employer

*Most Recent Title:

*Most Recent Pay:

*Exact Reason for Leaving:

May we contact this reference? Yes No

---*Name of Employer:

Address:

Street

Telephone Number:

Your Supervisor’s Name:

*Date of Employment:

*Starting Title:

*Starting Pay:

From:

To:

Current Employer

*Most Recent Title:

*Most Recent Pay:

*Exact Reason for Leaving:

---*Name of Employer:

Address:

Street

Telephone Number:

Your Supervisor’s Name:

*Date of Employment:

*Starting Title:

*Starting Pay:

From:

To:

Current Employer

*Most Recent Title:

*Most Recent Pay:

*Exact Reason for Leaving:

---*Name of Employer:

Address:

Street

Telephone Number:

Your Supervisor’s Name:

*Date of Employment:

*Starting Title:

*Starting Pay:

From:

To:

Current Employer

*Most Recent Title:

*Most Recent Pay:

*Exact Reason for Leaving:

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Criminal History

You are not obligated to disclose any reference to a pre or post trial diversion program, any conviction which has been sealed, expunged, annulled or erased by the court, or, if in California, any marijuana related misdemeanor conviction entered more than two years prior to the date of this employment application.

Please note that a “Yes” answer to these questions will not necessarily disqualify you from employment. Factors such as time of offense, seriousness and nature of the violation and rehabilitation will be considered when making any employment decisions.

*Have you ever, under your name or another name, been convicted or pleaded guilty to a criminal offense other than minor traffic violation? Yes No *If yes, please state the nature of the offense and disposition of the case. Include dates and places.

Personal/Professional Reference

(Please provide all personal/professional references)

I do not have any personal/professional references.

Contact Name: Company: In what capacity?

Telephone: City:

How long have you known him/her? State/Province: ---Contact Name: Company: In what capacity? Telephone: City:

How long have you known him/her? State/Province:

Do you have additional personal/professional reference? Yes No

Certification

By my signature placed below, I promise that I have personally completed this application. I understand that this application form is intended for use in

evaluating my qualifications for employment and that this application is not an offer of employment. I declare under penalty of perjury that the

information provided in this employment application, resume or on other written materials is true and complete. I also understand that any false

information, misrepresentations or significant omissions may disqualify me from further consideration for employment, and may be justification for my

dismissal from employment if discovered at a later date. I understand that any job offer will be conditional based on the satisfactory review of my

qualifications including any and all background or drug screening which may be required.

I voluntarily and knowingly authorize any present; or past employer; supervisor; administrator; educational institution; law enforcement agency; state;

local, or federal agency; private business; military branch; personal reference, and/or other persons; including consumer reporting bureaus to give

records or information they may have concerning my criminal history, educational, history, employment (including character, earnings history and

reason for termination) or any other information requested by the company and/or its agents to determine my eligibility for employment.

I voluntarily waive all recourse and release any company, individual or organization from liability for complying with any request from the company or

agents of the company to obtain any information from any source whatsoever relating to my application for employment. I further release the company

or any individual within the company regarding the use of any information received which may have bearing on my application for employment

Print Name: ________________________________________

Signature: __________________________________________

Date: ___________________________________

*Handwritten signature required

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Disclosure and Authorization

Background Check Disclosure and Authorization Form

In the interest of maintaining the safety and security of our customers, employees and property, the “Company” will order a “consumer report” (a background report) on you in connection with your employment application, and if you are hired, or if you already work for the company, may order additional background reports on you for employment purposes.

The “Company” uses, Transunion, ADP Screening, Backgroundchecks.com & Selection Services to prepare the background reporting. Located at: Transunion

2 Baldwin Place, P.O. Box 1000 Chester, PA 19022

800-888-4213

ADP Screening & Selection Services Backgroundchecks.com

301 Remington Street 12770 Coit Road, Suite 1150

Fort Collins, CO 80524 Dallas, Texas 75251

800-367-5933 866-300-8524

The background report may contain information concerning your character, general reputation, personal characteristics, mode of living and credit standing. The types of information that may be ordered include but are not limited to: Social Security number validation; criminal, public, educational and, as appropriate, driving record checks; verification of prior employment; reference, licensing and certification checks; credit reports; and drug testing results. The information may be obtained from private and public record sources, including personal interviews with your associates, friends and neighbors. (An “investigative consumer report” is a background report that includes information from such personal interviews, except in California where that term means any background report.) The nature and scope of the most common form of investigative consumer report is an investigation into your education and/or employment history conducted by ADP Screening and Selection Services or another outside organization. A summary of your rights under the Fair Credit Reporting Act is also being provided.

The Fair Credit Reporting Act gives you specific rights in dealing with consumer reporting agencies. You will find these rights summarized on the “A Summary of Your Rights Under the Fair Credit Reporting Act”.

Authorization Form

After carefully reading this Background Check Disclosure and Authorization form, I authorize the Company to order my background report, including investigative consumer reports. I understand that the Company may rely on this authorization to order additional background reports, including investigative consumer reports, during my employment without asking me for my authorization again as allowed by law.

I also authorize the following agencies and entities to disclose to disclose to ADP Screening and Selection Services and its agents all information about or concerning me, including, but not limited to: my past and present employers; learning institutions, including colleges and universities; law enforcement and all other federal, state and local agencies; federal state and local courts; the military; credit bureaus; testing facilities; motor vehicle record agencies; all other private and public sector repositories of information; and any other person, organization, or agency with any information about or concerning me. The information that can be disclosed to ADP Screening and Selection Services and its agents includes, but Is not limited to, information concerning my employment history, earnings history, education, credit history, motor vehicle history, criminal history, military service, professional credential and licenses and substance abuse test. I agree the Company may rely on this authorization to order background report, including investigative consumer reports, from companies other than ADP Screening and Section Services without asking me for my authorization again as allowed by law. I agree that a copy of this form is valid based on my acknowledgement below. If you live or work for the Company in California, Minnesota or Oklahoma: Check this box if you would like a free copy of your background check report.

I request a free copy of the report.

Name:

Last

Current Address:

Street

Social Security Number:

Date of Birth (For Identification Purposes Only):

Driver License Number:

Or No Drivers License

First

State Issuing Drivers License:

Middle Name or No Middle Name

City/State/Province *Zip/Postal Code

Country:

Ethnic and Gender Information:

Are you Hispanic or Latino?

Male Female (This information is for identification purposes only. Some states require sex and race for criminal history purposes)

Yes No

If you answered No to “Are you Hispanic or Latino”, please indicate what race you believe yourself to below:

American Indian or Alaskan Native (Not Hispanic or Latino) Asian (Not Hispanic or Latino)

Black or African American (Not Hispanic or Latino)

Native Hawaiian or other Pacific Islander (Not Hispanic or Latino) White (Not Hispanic or Latino)

Two or more races (Not Hispanic or Latino)

Enter Any Other Names Used: Name:

Last First Middle Name or No Middle Name

Signature: __________________________________________

Date: __________________________________

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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.ftc.gov/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 told if information in your file has been used against you. Anyone

who uses a credit report or another type of consumer report to deny your application for credit, insurance, employment - or to take another adverse action against you – must tell you, and must give you the name, address, and phone number of the agency that provided the information.

 You have the right to know what is in your file. 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. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:

 A person has taken adverse action against you because of information in your credit report;

 You are the victim of identify 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. In addition, by September 2005 all consumers will be 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.

 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. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.

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 Interstate Commerce Commission

Activities subject to the Packers and Stockyards Act, 1921

 You have the right to dispute incomplete or inaccurate information. If 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 delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must

be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.

 Consumer reporting agencies may not report outdated negative information. In

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 file is limited. 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.

 You must give your consent for reports to be provided to employers. 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 limit "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 1-888-567-8688.

 You may seek damages from violators. If 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 military personnel have additional rights.

For more information, visit www.ftc.gov/credit.

States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. Federal enforcers are:

CONTACT:

Federal Trade Commission: Consumer Response Center - FCRA Washington, DC 20580

1-877-382-4357

Office of Comptroller of the Currency Compliance Management

Mail Stop 6-6 Washington, DC 20219 800-613-6743

Federal Reserve Consumer Help (FRCH) P O Box 1200, Minneapolis, MN 55480 888-851-1920

www.federalreserveconsumerhelp.gov [email protected] Office of Thrift Supervision Consumer Complaints Washington, DC 20522 800-842-6929

National Credit Union Administration 1775 Duke Street

Alexandria, VA 22314 703-519-4600

Federal Deposit Insurance Corporation Consumer Response Center 2345 Grand Avenue, Suite 100 Kansas City, Missouri 64108-2638 1-877-275-3342

Department of Transportation Office of Financial Management Washington, DC 20590 202-366-1306 Department of Agriculture

Office of Deputy Administrator-GIPSA Washington, DC 20250