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Online Employment Application
Step
1
of
6
16%
Referred By
(Required)
Please list who referred you to Southern Electric Corporation.
Applicant Information
Full Legal Name
(Required)
First
Last
Current Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
(Required)
Email
(Required)
Date Available
(Required)
MM slash DD slash YYYY
Date of Birth (mm/dd/yyyy)
(Required)
MM slash DD slash YYYY
Social Security Number ( no spaces, dashes, etc )
(Required)
Drivers License Number ( no spaces, dashes, etc )
(Required)
State Issued
(Required)
Select One
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
License Expiration Date
(Required)
MM slash DD slash YYYY
Do you have reliable transportation?
(Required)
Yes
No
Desired Salary
(Required)
Are you bilingual?
(Required)
Yes
No
If you selected yes to the question above, please list the languages you speak fluently.
Position Applied For
(Required)
Select One
Electrician
Overhead Distribution
Overhead Transmission
Underground Electrical
Mechanics
Safety
Office
Overhead Distribution Position
(Required)
Select One
Superintendant
General Foreman
Foreman
Lineman A
Lineman B
Lineman C
Groundman
Operator
Overhead Transmission Position
(Required)
Select One
Superintendant
General Foreman
Foreman
Lineman A
Lineman B
Lineman C
Groundman
Operator
Electrician Position
(Required)
Select One
Superintendant
Master Electrician
Journey Electrician
Apprentice
Helper
Related Experience
(Required)
Please list any and all experience, training, or certification you might have relating to the "Position Applied For"
Are you a citizen of the United States?
(Required)
Yes
No
Are you authorized to work in the U.S.?
(Required)
Yes
No
Have you ever worked for this company?
(Required)
Yes
No
When have you worked for this company?
(Required)
Driving Experience
Please list the type of equipment you have experience with and how much?
(Required)
What class is your driver's licence?
(Required)
Class A CDL
Class B CDL
Regular
Do you have a valid medical card?
(Required)
Yes
No
N/A
Medical Card Expiration Date
(Required)
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
(Required)
Yes
No
Has any license, permit or privilege ever been suspended or revoked?
(Required)
Yes
No
If you answered yes to either of the above 2 questions, explain below
(Required)
List accident record for the past 3 years. Include the date, description and number of injuries/fatalities for each
(Required)
List traffic convictions and forfeitures for the past 3 years. Include the location, date, charge and penalty for each
(Required)
Special Questions
The information requested in this section is required for a bona fide occupational qualification or dictated by National Security Laws or is needed for other legally permissible reasons.
Height
(Required)
Weight
(Required)
What is your FR pant size? (please include the waist and length)
(Required)
What is your FR shirt size? (please indicate regular or long)
(Required)
What is your rubber glove size?
(Required)
What is your rubber sleeve size?
(Required)
What is your rubber boot size?
(Required)
Have you ever been convicted of a felony?
(Required)
Yes
No
If so, when and please provide the nature of the offense.
(Required)
Have you ever been denied employment for failure to provide your employer with a satisfactory drug screen or drug test in the last 3 years?
(Required)
Yes
No
I understand and agree that I may be required to take physical examination test(s) as a condition of hiring or continued employment. I agree to consent to take such test(s) at such time as designated by the company and to release the company, its Directors, Officers, Agents or employees from any claim arising in connection with the use of such test(s).
(Required)
Yes
No
I have been advised that drug testing is required as a condition of hiring or continued employment.
(Required)
Yes
No
Previous Address Information
Please list home addresses for the last 3 years, if different than current address.
Previous Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Previous Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Previous Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Education
High School
(Required)
Address
(Required)
Years Attended
(Required)
Did you graduate?
(Required)
Yes
No
College
(Required)
Address
(Required)
Years Attended
(Required)
Did you graduate?
(Required)
Yes
No
Degree
(Required)
Trade School
(Required)
Trade School Type
(Required)
Address
(Required)
Did you graduate?
(Required)
Yes
No
Other Education
Address
Years Attended
Did you graduate?
Yes
No
Degree
Do you have any computer experience?
(Required)
Yes
No
If yes, what do you have experience in?
(Required)
Email
Internet
Excel
Word
Are you willing to recieve computer training?
(Required)
Yes
No
References
Please list three professional references. Include full name, company name, address, relationship and contact information for each.
References
(Required)
Previous Employment
Classification and pay will be determined by employment history listed below.
Company
(Required)
Describe duties performed.
(Required)
Address
(Required)
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
(Required)
Supervisor
(Required)
First
Last
Salary
(Required)
Start/End Dates
(Required)
Reason For Leaving
(Required)
Were you subject to the Federal Motor Carrier Safety Administration (DOT) while employed?
(Required)
Yes
No
Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug & alcohol testing requirements of 49 CFR 40?
(Required)
Yes
No
Company
(Required)
Describe duties performed.
(Required)
Address
(Required)
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
(Required)
Supervisor
(Required)
First
Last
Salary
(Required)
Start/End Dates
(Required)
Reason For Leaving
(Required)
Were you subject to the FMCSRs while employed?
(Required)
Yes
No
Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug & alcohol testing requirements of 49 CFR 40?
(Required)
Yes
No
Company
(Required)
Describe duties performed.
(Required)
Address
(Required)
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
(Required)
Supervisor
(Required)
First
Last
Salary
(Required)
Start/End Dates
(Required)
Reason For Leaving
(Required)
Were you subject to the FMCSRs while employed?
(Required)
Yes
No
Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug & alcohol testing requirements of 49 CFR 40?
(Required)
Yes
No
Company
(Required)
Describe duties performed.
(Required)
Address
(Required)
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
Supervisor
First
Last
Salary
(Required)
Start/End Dates
(Required)
Reason For Leaving
(Required)
Were you subject to the FMCSRs while employed?
(Required)
Yes
No
Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug & alcohol testing requirements of 49 CFR 40?
(Required)
Yes
No
Company
Describe duties performed.
Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
Supervisor
First
Last
Salary
Start/End Dates
Reason For Leaving
Were you subject to the FMCSRs while employed?
Yes
No
Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug & alcohol testing requirements of 49 CFR 40?
Yes
No
Company
Describe duties performed.
Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
Supervisor
First
Last
Salary
Start/End Dates
Reason For Leaving
Were you subject to the FMCSRs while employed?
Yes
No
Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug & alcohol testing requirements of 49 CFR 40?
Yes
No
Company
Describe duties performed.
Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
Supervisor
First
Last
Salary
Start/End Dates
Reason For Leaving
Were you subject to the FMCSRs while employed?
Yes
No
Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug & alcohol testing requirements of 49 CFR 40?
Yes
No
Company
Describe duties performed.
Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
Supervisor
First
Last
Salary
Start/End Dates
Reason For Leaving
Were you subject to the FMCSRs while employed?
Yes
No
Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug & alcohol testing requirements of 49 CFR 40?
Yes
No
Declaration of Employment Status
I understand that I must provide my complete employment history for the past 3 years, and all CDL required employment for the 7 years preceeding that. Any gaps in employment longer than 1 month are explained as follows:
From
(Required)
To
(Required)
During this time, I was engaged in the following activity
(Required)
In addition
(Required)
I was not employed by any company or individual
I was not convicted of any criminal act involving the use of a commercial motor vehicle or while driving a commercial motor vehicle
From
(Required)
To
(Required)
During this time, I was engaged in the following activity
(Required)
In addition
(Required)
I was not employed by any company or individual
I was not convicted of any criminal act involving the use of a commercial motor vehicle or while driving a commercial motor vehicle
From
(Required)
To
(Required)
During this time, I was engaged in the following activity
(Required)
In addition
(Required)
I was not employed by any company or individual
I was not convicted of any criminal act involving the use of a commercial motor vehicle or while driving a commercial motor vehicle
Military Service
Branch
Date of Service
Rank at Discharge
Type of Discharge
If other than honorable, explain
Physical Record
Do you have any physical limitations that preclude you from performing any work for which you are being considered?
(Required)
Yes
No
If yes, please describe
(Required)
What can be done to accommodate your limitation?
(Required)
In case of emergency, whom should we notify?
(Required)
Disclaimer
^ I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you. I understand that by applying for this position I give Southern Electric Corporation permission to access my motor vehicle record. I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without prior notice. I authorize you to make such investigations and inquiries of my personal employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons of from all liability in responding to inquiries and releasing information in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interviews may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company. I understand that information I provide regarding current and/or previous employers may be used, and those employers will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23 (d) and (e). I understand that I have the right to: • Review information provided by the previous employers; • Have errors in the information corrected by previous employers and for those previous employers to re-send the correct information to the prospective employer; and • Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.
(Required)
I Agree
Electronic Signature
(Required)
Enter your name here as an electronic signature
CONSUMER REPORT DISCLOSURE
Southern Electric Corporation of MS (the “company”) intends to obtain and use a consumer report from Justifacts Credential Verification, Inc, an external consumer reporting agency, to be used for employment purposes. These purposes may include but are not limited to: * To obtain a copy of your motor vehicle record * Making a decision whether to allow you to drive for employment purposes * Making a decision whether to allow you to operate a company vehicle ACKNOWLEDGMENT I hereby acknowledge receipt of this disclosure and that Southern Electric Corporation of MS may obtain consumer reports about me from a consumer reporting agency and that they may consider information in consumer reports as part of their decision making process regarding any aspect of my application for employment and/or continued employment with the company, including periodic re-screening of current employees. I also acknowledge that I have received a copy of the Summary of Rights under the Fair Credit Reporting Act.
ELECTRONIC SIGNATURE
This Acknowledgement and Certification of Understanding ("Acknowledgement") is to let you know that by submitting an electronic signature, you are providing an electronic mark, that is held to the same standard as a legally binding equivalent of a handwritten signature provided by you. For purposes of the acknowledgement, a digital mark is considered a typed legal First and Last name (legal name may include middle name, initial or suffix) followed by the typed date. Any document requiring an electronic signature maycontain a signature acknowledgment statement provided in the same area requiring the electronic signature
Electronic Signature
(Required)
Enter your name here as an electronic signature
Full Legal Name
(Required)
Date
(Required)
MM slash DD slash YYYY
General Consent for Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol Clearinghouse
(Required)
I hereby provide consent to Southern Electric Corporation to conduct a limited query of the FMSCA Commercial Driver’s License Drug and Alcohol Clearinghouse (Clearinghouse) to determine whether drug or alcohol violation information about me exists in the clearinghouse. I also give my consent for Southern Electric Corporation to conduct an unlimited amount of limited queries throughout the duration of my employment. I understand that if the limited query conducted by Southern Electric Corporation indicated that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information to Southern Electric Corporation without first obtaining additional specific consent from me. I further understand that if I refuse to provide consent for Southern Electric Corporation to conduct a limited query of the Clearinghouse, Southern Electric Corporation must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA’s drug and alcohol program regulations.
I GIVE MY CONSENT
I DO NOT GIVE MY CONSENT
Electronic Signature
(Required)
Enter your name here as an electronic signature
Full Legal Name
(Required)
Date
(Required)
MM slash DD slash YYYY
AUTHORIZATION FOR BACKGROUND CHECK
I hereby authorize Southern Electric Corporation of Mississippi and/or any entity directed by Southern Electric Corporation of Mississippi to conduct a reference check and to obtain an investigative consumer report and/or consumer credit report for employment purposes, including, in connection with, my application for employment or continued employment. An “investigative consumer report” includes any information as to your character, general reputation, personal characteristics or mode of living. A “consumer credit report” includes any information regarding your credit worthiness, credit standing or credit capacity. The specific nature and scope of the investigative consumer report may include inquiries regarding educational background; work history; personal financial status and credit history; workers compensation claims; court records, including criminal conviction records as permitted by law; driving history; verification of Social Security Number; and references obtained from professional and personal associates. I further understand and agree that an investigative consumer report and/or consumer credit report may be obtained at any time, and any number of times, as the Company in its sole discretion determines it is necessary before, during or after my employment. I understand that I may request a copy of the investigative consumer report provided to Company. I acknowledge receipt of the attached summary of rights regarding an investigative consumer reporting agency’s obligations pursuant to the Fair Credit Reporting Act. I hereby authorize all previous employers, educational institutions, consumer reporting agencies and other persons or entities having information about me to provide such information to Company or other entity that obtains information for Company. I further fully release Company, its employees, officers, directors, agents, successors and assigns, and all other parties involved in this background investigation, including, but not limited to, investigators, credit agencies and those companies or individuals who provide information to Company concerning me from any claims or actions for liability whatsoever related to the process or results of the background investigation. I understand that an offer of employment is contingent upon the outcome of my background check, and that this Disclosure and Authorization is not an offer for employment by Company or a contract for employment with Company. I further understand Company operates under an AT-WILL EMPLOYMENT POLICY and this Authorization does not alter or affect that policy in any manner whatsoever.
Electronic Signature
(Required)
Enter your name here as an electronic signature
Full Legal Name
(Required)
Date
(Required)
MM slash DD slash YYYY
Untitled
Untitled
Untitled
Email
This field is for validation purposes and should be left unchanged.
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