APPLICANT S STATEMENT I understand that the Company is committed to providing equal opportunity in all employment practices, including but not limited to selection, hiring, promotion, transfer, and compensation to all qualified applicants and employees without regard to age, race, color, national origin, sex, religion, handicap or disability, or any other category protected by federal, state, or local law. I authorize former and present employers, and professional, work and personal references listed in the application and any other individuals I may name, to give the Company or its designee any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise and release such parties from all liability for any damages that may result from furnishing same to the Company. I also authorize the Company to provide truthful information concerning my employment with it to future employers and I agree to hold it harmless for providing such information. I understand that the Company reserves the right, to the extent permitted by law, to require drug and alcohol screening tests of an applicant or employee either prior to employment or any time during employment and I hereby give my consent to any such test. I consent to the release of the results of any such tests to the Company or its designee. I release the Company and its designee from any and all liability and damages which may result or arise from any drug test or the provision of information in connection with such a test. I understand that this employment application and any other Company documents are not promises of employment. If I am hired and not employed pursuant to a contract of employment that contains a specific duration of employment my employment is at will. I further understand that, if I am employed, I can terminate my employment at any time with or without cause and with or without advance notice, and that the Company has a similar right. I understand that no manager, representative, or agent of the Company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, except that the President may do so in writing. If I am hired under a contract, the contract will control the terms of my employment. The information given by me on this application and during the interview process is true and complete in all respects, and I agree that if the information is found to be false, misleading, or unsatisfactory in any respect (in the Company s judgment) that I will be disqualified from consideration for employment or subject to immediate dismissal if discovered after I am hired. I CERTIFY THAT I HAVE RECEIVED AS SEPARATE WRITTEN NOTIFICATION THAT THE COMPANY MAY OBTAIN A CONSUMER REPORT ON ME FOR USE IN CONNECTION WITH MY APPLICATION AND, IF I AM HIRED, MY EMPLOYMENT WITH THE COMPANY. I AUTHORIZE THE COMPANY TO OBTAIN THIS REPORT. THIS APPLICATION WILL BE CONSIDERED ACTIVE FOR A MAXIMUM OF THIRTY (30) DAYS IF YOU WISH TO BE CONSIDERED FOR EMPLOYMENT AFTER THAT TIME, YOU MUST REAPPLY. DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THESE STATEMENTS. APPLICATION FOR EMPLOYMENT (first) Applicant s Signature PERSONAL INFORMATION Name Social Security Number Present address Since Home Number ( ) Work Number ( ) Cell Number ( ) Email / / Location of position applying for Full time or Part Time Position applying for Requested Salary Available start date / / How did you hear about this position? Were you referred to this position by someone in the company Yes or No if so who? Are you willing to work flexible hours, which may or may not include weekends and/or overtime? Yes or No Are you 18 years or older? Yes or No If under 18 years of age, can you obtain a work permit? Yes or No Have you ever obtain work under another name? Yes or No If yes, please explain: Have you ever applied or been employed by our company before? Yes or No If yes, when? / / Where? Who was your immediate supervisor? Are you related to or acquainted with any employees of this company? Yes or No If yes, please explain: If hired, can you provide proof that you are legally entitled to work in the U.S.? Yes In the event of an emergency, who should be contacted? Name or No 1
Do you know of any reason why you cannot perform the essential functions of the job for which you are applying, with or without accommodations? Yes or No Please describe any accommodations required: Please list any organization or professional group and the offices you held which have direct bearing upon your qualifications for the job which you are seeking. You may exclude those clubs, etc. which, by nature, would identify your race, religion, national origin, ancestry, age, sex, color, marital status, or physical or mental handicap: Have you ever been bonded? Yes or No If yes, on what jobs? EDUCATION School Name Elementary: Years Completed (circle) Diploma/Degree Describe Course of Study or Major Describe Specialized Experience, Training, Skills, and Extra-Curricular Activities 4 5 6 7 8 High School: 9 10 11 12 College/University: Graduate/Professional: Trade or Correspondence: Can you type? Yes or No If yes, how many words per minute: WPM List any academic prizes, honors or awards received: List any professional designations, certifications, licenses, or courses that may be applicable to the position for which you are applying: Do you speak or write any foreign languages? Yes or No If yes, please list: EMPLOYMENT HISTORY Please list the names of your present or previous employers in chronological order with present or last employer listed first. Include part-time and seasonal employment. If self-employed, give firm name and supply business references. DO NOT ANSWER SEE RESUME. Fill out this form completely. Have you ever been terminated or asked to resign from any job? Yes or No If yes, please explain circumstances: Do you have any commitments to any other employer which may affect your employment? Yes or No If yes, please explain: May we contact your present employer? Yes or No Employer 1 Phone( ) Employer 2 Phone( ) 2
Employer 3 Phone( ) Employer 4 Phone( ) Employer 5 Phone( ) Please explain fully any gaps in your employment history. Be sure to account for all periods of time including military service and and period of unemployment. MILITARY SERVICE RECORD *If not applicable write; N/A entered service / / Highest rank held discharged / / Rank at time of discharge Are you a member of the Active Reserves? Yes or No If yes, what is your obligation? Did you receive any special commendations or recognition? Do you have an honorable discharge? Yes or No If your discharge was other than honorable, please explain type of discharge. *Discharges other than honorable are not necessarily a bar to employment; however, deception as to the exact nature of discharge will result in denial of employment or a subsequent discharge with cause should you be hired: PROFESSIONAL REFERENCES *not relatives Name Relationship Telephone Number Business Type DRIVING INFORMATION *Complete only if driving is an essential function of the job for which you are applying. Do you have a current valid driver s license? Yes or No If yes, License No. State: Expiration : / / If you do not have a driver s license for the state in which you currently reside, why not? Has your license ever been suspended or revoked? Yes or No If yes, explain: Do you have personal automobile insurance? Yes or No If yes, explain: 3
Have you ever been denied personal automobile insurance or has it ever been terminated or suspended? Yes or No If yes, explain: Have you ever been convicted, pled guilty, or pled nolo to a charge of DWI or DUI? Yes or No Are any such charges currently pending against you? If yes to either question, explain: Please list all moving traffic violations in the last five (5) years: Offense Locaton Comments NOTE: Answering Yes to these questions does not constitute an automatic bar to employment. Factors such as the age and time of offense, seriousness and nature 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.) Signature FOR PERSONNEL DEPARTMENT USE ONLY Interview conducted by Employment records verified per dates Hired. Start date: / / References checked. Not Hired. Remarks: 4
APPLICANT RELEASE In connection with my application for employment, I understand that investigative background inquiries are to be made on me including consumer credit, criminal convictions, motor vehicle, and other reports. Further, I understand that your company will be requesting information from various Federal, State, and other agencies which maintain records concerning my past activities relating to my driving, credit, criminal, civil, and other experiences as well as claims involving me in the files of insurance companies. I authorize without reservation, any party or agency contacted to furnish the above mentioned information and release all parties involved from liability and responsibility for doing so. This authorization and consent shall be valid in original, fax, or copy form. The following information is required by law enforcement agencies and other entities for identification purposes when checking records. It is confidential and will not be used for any other purpose: Please print clearly: Print Full Name: Print other names you have used: s used: of Birth (mm/dd/yyyy) : / /.Social Security Number: - - : City: State: Zip Code: Current Driver s License Number: Issuing State: Expires: / / Other Driver s License Number: Issuing State: Expires: / / (List last seven (7) years only) Circle appropriate response for each question Have you ever been arrested, cited, prosecuted, plead guilty to, or been convicted of a crime? *exclude minor/simple traffic violations YES NO Have you ever been placed on probation, parole, or affected by the Megan Law? YES NO Have you ever been or currently are a member of a gang? YES NO Have you ever had or currently have a warrant for your arrest? YES NO Have you ever been or currently are involved in ANY criminal activity? YES NO Have you ever been evicted or had a forcible detainer filed against you? YES NO Have you ever moved to avoid eviction or because of problems with other tenants or a landlord? YES NO Explain ALL YES answers in detail: Do you have a legal right to be in the United States: Yes, I am a U.S. Citizen Yes, I have valid documentation from the U.S. Department of Immigration and Naturalization (INS) that allows me to be in the Country No I understand that Kole Management Company has the right to request documentation that demonstrates U.S, citizenship or a valid visa entry according to the INS. Signature 5