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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

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.

I Agree

Electronic Signature(Required)

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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

Electronic Signature(Required)

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Full Legal Name(Required)

Date(Required)

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)

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Full Legal Name(Required)

Date(Required)

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)

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Full Legal Name(Required)

Date(Required)

Untitled

Name

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SOUTHERN ELECTRIC CORPORATION LLC
OFFICE (601) 939-2333
FAX (601) 939-2261
info@secofms.com
P.O. Box 320398
Flowood, MS 39232
WWW.SECOFMS.COM

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Applicant Information

Driving Experience

Special Questions

Previous Address Information

Education

References

Previous Employment

Declaration of Employment Status

Military Service

Physical Record

Disclaimer