Employer Flexible HR © Copyright 201 , All rights reserved (Please Print) Application Date: Date Available To Work: Position Applied For: Name: Last First Middle Desired Wage: Desired Work Type: Full Time Part Time Temporary Shift 1 Shift 2 Shift 3If Part Time, Specify Hours or Days Available: Current Address: Street Apt # City State Zip Code How Long At Current Address? Previous Address: Street Apt # City State Zip Code How Long At Previous Address? Primary Phone Number: Secondary Phone Number: Email Address: Are you capable of performing the essential duties of the position you are being hired or interviewed for, with or without reasonable accommodation? Yes or No What accommodations if any would be necessary? Can you, after employment, submit verification of your legal right to work in the United States? Yes No Have you previously held employment with Employer Flexible HR, and / or the Employer Flexible HR, client company -Santa Maria Hostel you are applying for? Yes No If yes, give dates: From: To: ave you Employer Flexible HR, r Yes No If yes, give dates: From: To: RECORD OF PREVIOUS EMPLOYMENT Please list the names of your present employers in chronological order with present or last employer listed first. Be sure to account for all periods of time including military service and any period of unemployment. If self-employed, give firm name and supply business references. (Add additional page if necessary). Present or Last EmployerEmployed Pay Your Title or Position: Exact Reason for Leaving From (mo/yr) Start $ City, ST, ZipTo (mo/yr) Final $ Description of Duties: May we contact this employer? TelephoneSupervisor’s Name and Title: Previous EmployerEmployed Pay Your Title or Position: Exact Reason for Leaving From (mo/yr) Start $ Address City, ST, ZipTo (mo/yr) Final $ Description of Duties: May we contact this employer? TelephoneSupervisor’s Name and Title: EMPLOYMENT GAPS: School Name City, State Degree / Diploma Major Course of Study Degree Received? High School / GED Yes No College Yes No Graduate School Yes No Trade School Yes No List any other education, training, special skills, certificates, or licenses that you possess related to the position. School Name City, State Degree / Diploma Major Course of Study Degree Received? High School / GED Yes No Employer Flexible HR © Copyright 201 , All rights reserved I hereby certify that the facts set forth in the above employment application (and resume if included) are true and complete to the best of my knowledge and that if I am hired, falsified statements of any kind or omissions of facts called for on this application (and resume if attached) shall be considered sufficient basis for dismissal. I fully authorize all persons listed above (and within my resume if included) to give Employer Flexible HR, any and all information requested to verify their accuracy and to obtain reference information on my work performance. I hereby release Employer Flexible HR, from any/all liability of whatever kind and nature which, at any time, could result from obtaining and having an employment decision based on such information. I understand that should an employment offer be extended to me and accepted that I will fully adhere to the policies, rules, and regulations of employment of Employer Flexible HR, Inc. and its client. However, I further understand that neither the policies, rules, regulations of employment, nor anything said during the interview process shall be deemed to constitute the terms of an implied employment contract. I understand that any employment offered is for an indefinite duration and at will and that either I or the Employer may terminate my employment at any time with or without notice or cause. I understand that Employer Flexible HR, and its client have agreed that Employer Flexible HR, compensation insurance coverage for its employees. In the event of an injury in the workplace, I agree that my sole remedy lies in coverage under Employer Flexible HR, tion insurance policy. I understand and agree that, subject to applicable law, I may be required to take a drug and alcohol screening test. I hereby give my voluntary consent for a urine and / or blood sample to be collected from me and submitted for testing. I also consent to the release of the test results to Employer Flexible HR, and / or its client company. I understand that any positive drug or alcohol result may preclude my employment. Applicant Signature: Date: Applicant Name Printed: Employer Flexible HR © Copyright 2017, All rights reserved RELEASE OF LIABILITY I hereby release Employer Flexible HR, LLC , Raintree Holdings, LLC, and Redstar Backgrounds Inc, their officers, employees, and agents, from any and all liability arising from the results of any investigation and the preparation of any reports concerning myself or my background. CRIMINAL RECORD DISCLOSURE: Answering “YES” to this question does not constitute an automatic bar to employment. Factors such as age and time of the offense, seriousness and nature of the matter of the violation, and rehabilitation will be taken into account. (Do not include minor traffic citations and arrests or convictions which have been sealed or expunged in answering this question.) Are you currently or have you ever been a party to any misdemeanor or felony criminal matter, other than minor traffic safety violations for which no arrest was made, in which you were charged, convicted, served probation, participated in deferred adjudication, or other program to avoid a conviction, or made restitution or participated in pre-trial diversion or other program to avoid prosecution? This includes if you have ever been arrested for any matters for which you are out on bail or on your own recognizance pending trial. Yes OR No Criminal Records: if you answered Yes to the above question, please provide the date(s) and describe that criminal record so the individual circumstances can be considered. Has your drivers license ever been suspended. Yes OR No If so, why? Signature: Screening Requested: To be Completed by Employer Criminal Background Drug MVR ($15) Credit ($15) Education ($36 each) Employment ($36 each) Requested by (print) Signature Date Requesting Company Client Company Employer Flexible HR © Copyright 2017, All rights reserved DISCLOSURE AND AUTHORIZATION FOR CONSUMER REPORTS Disclosure In connection with my application for employment (including contract or volunteer services) with Employer Flexible HR, LLC, I understand consumer reports will be requested by you (“Company”). These reports may include, as allowed by law, the following types of information, as applicable: names and dates of previous employers, work experience, education, accidents, licensure, credit (as allowed by law – where required, you will be presented with additional disclosures), etc. I further understand that such reports may contain public record information such as, but not limited to: my driving record, workers’ compensation claims, judgments, bankruptcy proceedings, evictions, criminal records, etc., from federal, state, and other agencies that maintain such records. In addition, investigative consumer reports (gathered from personal interviews, as applicable, with former employers or landlords, past or current neighbors and associates of mine, etc.) to gather information regarding my work or tenant performance, character, general reputation and personal characteristics, and mode of living (lifestyle) may be obtained. If I am hired, I understand that my employer can use this disclosure and authorization to continue to obtain such consumer reports throughout my employment, contract period, or volunteer service. Authorization I hereby authorize procurement of consumer report(s) and investigative consumer report(s) by Company. If hired (or contracted), this authorization shall remain on file and shall serve as ongoing authorization for Company to procure such reports at any time during my employment, contract, or volunteer period. I authorize without reservation, any person, business, or agency contacted by the consumer reporting agency to furnish the above- mentioned information. This authorization is conditioned upon the following representations of my rights: I understand that I have the right to make a request to the consumer reporting agency: 5D Investigations/SureHire 360 (“Agency”), 5315B FM 1960W., #268/8570 Katy Freeway, Suite 114, Houston, TX 77069/77024, telephone number 1-877.587.5374/800-677-8282, and upon proper identification, to obtain copies of any reports furnished to Company by the Agency and to request the nature and substance of all information in its files on me at the time of my request, including the sources of information, and the Agency, on Company’s behalf, will provide a complete and accurate disclosure of the nature and scope of the investigation covered by any investigative consumer report(s). The Agency will also disclose the recipients of any such reports on me which the Agency has previously furnished within the two year period for employment requests, and one year for other purposes preceding my request (California three years). I hereby consent to Company obtaining the above information from the Agency. I understand that I can dispute, at any time, any information that is inaccurate in any type of report with the Agency. I may view the Agency’s privacy policy at their website: www.5dinvestigations.com. Employer Flexible HR © Copyright 2017, All rights reserved I understand that if the Company is located in California, Minnesota or Oklahoma, that I have the right to request a copy of any report Company receives on me at the time the report is provided to Company. By checking the following box, I request a copy of all such reports be sent to me. Check here: As a California applicant, I understand that I have the right under Section 1786.22 of the California Civil Code to contact the Agency during reasonable hours (9:00 a.m. to 5:00 p.m. (CTZ) Monday through Friday) to obtain all information in Agency’s file for my review. I may obtain such information as follows: 1) In person at the Agency’s offices, which address is listed above. I can have someone accompany me to the Agency’s offices. Agency may require this third party to present reasonable identification. I may be required at the time of such visit to sign an authorization for the Agency to disclose to or discuss Agency’s information with this third party; 2) By certified mail, if I have previously provided identification in a written request that my file be sent to me or to a third party identified by me; 3)By telephone, if I have previously provided proper identification in writing to Agency; and 4) Agency has trained personnel to explain any information in my file to me and if the file contains any information that is coded, such will be explained tome. I understand that if I am applying for employment in New York, that I have the right to receive a copy of Article 23-A of the New York Correction Law (initial if this applies). I understand that if the report is provided to an employer in the State of Washington, that I can contact the following office for more information regarding my rights under Washington state law in regard to these reports: State of Washington Attorney General, Consumer Protection Division, 800 5thAve, Ste. 2000, Seattle, Washington 98104-3188, (206) 464-7744. In connection with my application for employment, I direct the following regarding my current employer: (please check one). Yes, my current employer may be contacted / No, my current employer cannot be contacted I understand that I have rights under the Fair Credit Reporting Act, and I acknowledge receipt of the Summary of Rights (initials). : Signature: Date: For identification purposes: Social Security No.: Date of Birth: Driver’s License No.: State of Issue: Street Address, City, State, Zip: Email: Employer Flexible HR © Copyright 2017, All rights reserved 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.consumerfinance.gov/learnmore or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552. 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, or employment – or to take another adverse action against you – must tell you,andmust give youthename, address,andphonenumberof theagencythatprovidedtheinformation. 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 manycases,thedisclosurewill befree.Youareentitledto a freefile disclosureif: oa person has taken adverse action against you because of information in your creditreport; oyou are the victim of identify theft and place a fraud alert in yourfile; oyour file contains inaccurate information as a result offraud; oyou are on public assistance; oyou are unemployed but expect to apply for employment within 60days. In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.consumerfinance.gov/learnmore 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 mortgagelender. 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.consumerfinance.gov/learnmorefor an explanation of disputeprocedures. 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 asaccurate. Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may notreportnegativeinformationthatis more thansevenyearsold,orbankruptciesthataremore than 10 yearsold. Access to your file is limited. A consumer reporting agency may provide information about you only to people with a validneed – usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need foraccess. 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 requiredin thetrucking industry.Formoreinformation, goto www.consumerfinance.gov/learnmore . 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 ofinformation to a consumer reportingagencyviolatestheFCRA,youmaybeableto suein stateorfederalcourt. Identity theft victims and active duty military personnel have additional rights. For more information, visit www.consumerfinance.gov/learnmore . Employer Flexible HR © Copyright 2017, All rights reserved 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. For information about your federal rights, contact: TYPE OF BUSINESS: CONTACT: 1. a. Banks, savings associations, and credit unions with total a. Consumer Financial Protection Bureau assets of over $10 billion and their affiliates. 1700 G Street NW Washington, DC 20552 b. Such affiliates that are not banks, savings associations, or b. Federal Trade Commission: Consumer Response Center – FCRA credit unions also should list, in addition to the CFPB: Washington, DC 20580 (877)382-4357 2. To the extent not included in item 1 above: a. National banks, federal savings associations, and federal a. Office of the Comptroller of the Currency Customer Assistance branches and federal agencies of foreign banks Group 1301 McKinney Street, Suite 3450 Houston, TX 77010-9050 b. State member banks, branches and agencies of foreign banks b. Federal Reserve Consumer Help Center (other than federal branches, federal agencies, and Insured P.O. Box 1200 State Branches of Foreign Banks), commercial lending companies Minneapolis, MN 55480 owned or controlled by foreign banks, and organizations operating under section 25 or 25A of the Federal Reserve Act c. Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured state savings associations d. Federal Credit Unions c. FDIC Consumer Response Center 1100 Walnut Street, Box #11 Kansas City, MO 64106 d. National Credit Union Administration Office of Consumer Protection (OCP) Division of Consumer Compliance and Outreach (DCCO) 1775 Duke Street Alexandria, VA 22314 3. Air carriers Asst. General Counsel for Aviation Enforcement & Proceeding Aviation Consumer Protection Division Department of Transportation 1200 New Jersey Avenue, SE Washington, DC 20590 4. Creditors Subject to Surface Transportation Board Office of Proceedings, Surface Transportation Board Department of Transportation 395 E Street S.W. Washington, DC 20423 5. Creditors Subject to Packers and Stockyards Act, 1921 Nearest Packers and Stockyards Administration area supervisor 6. Small Business Investment Companies Associate Deputy Administrator for Capital Access United States Small Business Administration 409 Third Street, SW, 8th Floor Washington, DC 20416 7. Brokers and Dealers Securities and Exchange Commission 100 F St NE Washington, DC 20549 8. Federal Land Banks, Federal Land Bank Associations, Federal Intermediate Credit Banks, and Production Credit AssociationsFarm Credit Administration 1501 Farm Credit Drive McLean, VA 22102-5090 9. Retailers, Finance Companies, and All Other Creditors Not FTC Regional Office for region in which the creditor operates or Listed Above Federal Trade Commission: Consumer Response Center –FCRA Washington, DC 20580 (877)382-4357
