AppLication for EmpLoyment › wp-content › uploads › 2015 › 04 › ... · employer, or insurance company to furnish any and all background infonnation requested by Datasource

AppLication for EmpLoyment Please Print

NOTICE TO APPLICANTS AND EMPLOYEES

Screening tests for illegal drug use may be required before hiring and during your employment here.

Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notifY a representative of the Human Resources Department.

Position(s) applied for _ Date of application __L.I /t...-_

Name -----.:=----------------,=------------;=r:- ­Last First M,ddle Applicant ID # _

Address Street City State ZIP Code

Telephone # .>...(__'-­ _ Cellular/Other # -'--_-L. _ E-mail Address _

If you are under 18 and it is required, can you furnish a work permit? . DYes ONo

If no, please explain: _

Have you ever been employed here before? If yes, give dates and positions: _ DYes ONo

Is this application a request for reemployment following an extended military leave of absence from this company? . DYes ONo If yes, additional information may be requested.

Are you legally eligible for employment in this country? 0 Yes 0 No

Date available for work / What is your desired salaly range? $ _

Type of employment desired: 0 Full-Time 0 Part-Time 0 Temporary 0 Seasonal 0 Educational Co-Op

Are you able to perform the "essential functions" of the job for which you are applying (With or without reasonable accommodation)?

This question is not designed to elicit information about an applicant's disability. Please do not provide information about the existence of a disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stage to the extent permitted by law.

DYes 0 No 0 Need more information about the job's "essential functions" to respond

Driver's license number required if driving may be required in the job for which you are applying: State

Answering "yes" to either part of the following question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.

Have yOll ever pleaded "guilty" or "no contest" to, or been convicted of, a crime? 0 Yes 0 No

If~s, please provide date(s) and detaiJs: ~

Employment History Starting with your most recent employer, provide the following information.

Monthtmp oyer Telep one. Month /Dates employed: '" to / '" ( )

O'Street address C.ty State

o Hourly o Salary I $ per::.taTting Jon title/Mal Jon title

Commission/Bonus/Other Compensation $ mme01ate supervlsor anome (ror most reeen posmon nelO) ,.May we eonrae or re erenee.

DYes ONo o Later o Hourly o Salary I $ per"ny 010 you eave.

t-mail: Commission/Bonus/Other Compensation $ )ummanze me [ype 0 worK pe armed and Jab responSll)1l10es.

/eo< MontoMOntn /Employer ( Telephone # ) Dates employed: to '"

,.::.treet address Lity ::.tate

o Hourly o Salary I $ per ::.tamng JOD tme/l na Jon me

Commission/Bonus/Other Compensation $ mmeala e supeMsor ana me {ror mos reeen posmon nelO} ,.May we con ae or re erenee.

DYes ONo o Later o Hourly o Salary I $ per"ny 0'0 you eave.

E-mail: Commission/Bonus/Other Compensation $ .)ummanze lne type a worK pe ormeu anu JOu responSl l.llles.

ont earMontn /tmp oyer ( e ep one. ) Dates employed: '" to

Street address City State /

o Hourly o Salary I $ per ::.taTting Jon t,tle/hnal Jon tltle

Commission/Bonus/Other Compensation $ May we CQntae or re erence.mmealate SupeTVlsor aMJtle (fOr most reeen posmon neld) O' 0

DYes ONo o Later o Hourly o Salary I $ per"ny 010 you eave.

E-mail: Commission/Bonus/Other Compensation $ .)ummanze me LYpe a worK pe ormea ana JOo responsl Illes.

AN EQUAL OPPORTUNITY EMPLOYER

Skills and Qualifications Summarize any special rraining, skills, licenses and/or certificates that may assist you in performing the position for which you are applying:

Computer Skills (Check appropriate boxes. Include software titles and years of experience.)

o Word Processing Years: DE-mail Years: ___

o Spreadsheet Years: o Internet Years: ___

o Presentation Years: o Other Years: ___

Educational Background Starting with your most recent school attended, provide the following information.

School (include City & State) Years Completed Completed GPA

Class Rank Major/Minor

o Diploma oGED

o Degree

o Certification

o Other

o Oiploma oGED

o Degree

o Certification

o Other

o Diploma oGED

o Degree

o Certification

L Other

References List names and telephone numbers of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you.

Name Title Relationship.~'H' Telephone E-mail #of Years to You ' Known

If )

if )

( )

Social Security Number 55# _ We will use this information only for employment purposes and make reasonable efforts to safeguard your privacy.

Applicant Statement I certifY that all information I have provided in order to apply for and secure work with this employer is true, complete and correct.

I expressly authorize, withom reservarion, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to orherwise verifY the accuracy of all informarion provided by me in this applicarion, resume or job interview. I hereby waive any and all rights and claims I may have regarding th~ employer, irs agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory informarion, in a lawful manner, in rhe employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that rhis employer does nOt unlawfully discriminare in employment and no quesrion on rhis applicarion is used for rhe purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, statc or federal law.

I undetstand rhat rhis applicarion remains current for only 30 days. At rhe conclusion of that rime, if I have nor heard from the employer and srill wish ro be considered for employment, it will be n~cessary for me to reapply and fill out a new application,

If I am hired, I understand [hat I am free to resign at any time, wirh or without cause and with or without prior notice, and the employer reserves the same righr to terminate my employment at any time, wirh or wirhout cause and with or without prior norice, excepr as may be required by law, This application does nor conSTitute an agreement or contract for employment for any specified period or definite duration, I understand thar no superviso[ o[ rep[esenta[ive of [he employer is authorized to make any assurances to [he contrary and rha[ no implied oral or wrinen agreements contrary to rhe foregoing exp[ess language arc valid unless they are in weiting and signed by [he employer's president,

I also undemand [hal if I am hired, J will be required ro provide proof of identity and legal authorization ro work in the Unired Slates and char federal immigrarion laws lequire me [Q complete an [-9 Form in this regard.

This Company does not tolerate omIawfu.l discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding an applicant from consideration for employment on the basis of his or her sex, race, color, religion, national origin, citizenship, age, disability, or any other protected status under applicable federal, state, or local law. Tltis Company likewise does not tolerate harassment based on sex, race, color, religion, national origin, citizenship, age, disability, or any other protected status. The Company takes all complaints of harassment seriously and all complaints will be investigated prompdy and thoroughly.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer's service, whenever it is discovered.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT. I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

Signature ofApplicant _ Date _-1-1__1-1__

<92008 G.Nc.i1 $mORJV~J G.Ndl usumn no responsibility (or the c:mploydl we of this (orm or any decision Ih~ c:mplo~~r makes 720 1fl1C'rn.uional P2dcway, Sunrist'. FL 3332S " _ thai (n:.lY viol:a(( local. m.le' or fwC'rall.tw. By :.c:lling this (orm, G.Ndl is not gh·jng I~al advia:.

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BACKGROUND CHECK AUTHORIZATION FCRA NOTICE AND ACKNOWLEDGMENT

IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING ACKNOWLEDGMENT

NOTICE REGARDING BACKGROUND INVESTIGATION Clegg's Termite and Pest Control. LLC ("the Company") may obtain infonnation about you from a consumer reporting agency for employment purposes. Thus,

you may be the subject of a ·consumer report" and/or an ·investigative consumer report" which may include, but is not limited to: employment and education verifications; social security number verification; criminal and civil court records; personal interviews; driving records; and/or any other pUblic records or any other infonnation bearing on your character, general reputation, personal characteristics and trustworthiness. These reports may be obtained at any time after receipt of your authorization and, if you are selected, throughout your affiliation with the Company. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report. The report will be generated by Datasource Background Screening (1200 South Outer Road, Blue Springs, MO 64015/816-228-5255) or another outside organization. The scope ofthis notice and authorization is all-encompassing, however, allowing the Company to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and, if you are selected, throughout your affiliation with the Company to the extent pennitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report.

ACKNOWLEDGMENT AND AUTHORIZATION I acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION (above) and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT (separate document) and certify that I have read and understand both of those documents. I hereby authorize the obtaining of ·consumer reports" and/or ·investigative consumer reports" at any time after receipt of this authorization and, if I am selected, throughout my affiliation with the Company. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), infonnation service bureau, employer, or insurance company to furnish any and all background infonnation requested by Datasource Background Screening, another outside organization acting on behalf of the Company, and/or the Company itself. I agree that a facsimile ("fax") or photographic copy of this Authorization shall be as valid as the original. Minnesota and Oklahoma applicants only: Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Company. [ I Applicants of New York Employers only: I acknowledge that by signing below, I have also received a copy of Article 23-A of the New York Correction Law, in compliance with Article 25 Section 380-g of the New York General Business Law. California applicants only: By signing below, you also acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW. Please check this box if you would like to receive a copy of an investigative consumer report or consumer credit report if one is obtained by the Company at no charge whenever you have a right to receive such a copy under California law. [ I

First Middle Last

Full Name

First Middle Last

Maiden Name, First Middle Last

Previous Names, or Aliases Used: First Middle Last

Driver's License Date of Birth: Driver's License Number:Social Security Number: State:

Please provide ALL residential addresses for the past seven (7) years.

Current Address: From

Previous Address: Fromrro

Previous Address: Fromrro

Previous Address: Fromrro

Previous Address: Fromrro

Previous Address: Fromrro

Previous Address: Fromrro

Previous Address: Fromrro

Contact Telephone Number: Check here if there are more addresses you have lived at in the last 7 years. D

SIGNATURE: DATE: