Personal Data First Name Middle Last Date Mailing Street Address City State Zip Permanent Street Address (if different than above) City State Zip Home Phone Cell Phone Email Are you legally authorized or permitted to work in the United States? Are you 18 or over? Have you ever been convicted of a crime?** (Answering yes to this question will be an absolute bar to an offer of employment.) If Yes, please explain. Attach additional sheet(s) if necessary. *California and Illinois applicants: Please read the Notice to Applicants section on the reverse side of this application prior to answering this question. Yes No Yes No Yes No Placement Information Position or type of work desired Full Time Part Time Temporary Seasonal AM PM Hours Available to Work Overtime Required All If not All, please complete schedule below indicating starting and ending times Sunday Monday Tuesday Wednesday Thursday Friday Saturday Salary or Wage Desired Date Available Who or What Referred you to Mace Security International (MSI)? Have you ever been employed by an operating company of MSI, Inc. before? Yes No If Yes, when and where?... Page 1 of 6 v 0911
Education Record List Last High School and All Business, Trade Schools and Colleges Attended Name and Location of School Major/Minor Degree Cumulative GPA Extracurricular Activities (Include Offices held, Scholarships, awards, honors, sports, etc.) You are not required to list activities which may reveal your Race, Religion, Sex, or national Origin. Employment History List All Employers With Current or Most Recent Employment First. Leave no Time Unaccounted For. Present/Last Employer Dates Employed Supervisor Reason for Leave or Seeking Change of Position May We Contact Your Current Employer? Telephone Number Email Yes No Page 2 of 6 v 0911
First Previous Employer Dates Employed Supervisor Reason for Leave or Seeking Change of Position Next Previous Employer Dates Employed Supervisor Reason for Leaving or Seeking Change of Position Next Previous Employer Dates Employed Supervisor Reason for Leave or Seeking Change of Position Page 3 of 6 v 0911
Business Personal Occupational s List Personal s only if you have no Occupational s Name Occupation Years Acquainted Business Personal Name Occupation Years Acquainted Business Personal Name Occupation Years Acquainted In order to check references and complete background check, please list any other name(s) you have worked under Important. Read Before Signing. The filing of an application with MSI, Inc. is a preliminary step to employment. It does not obligate MSI, Inc. to offer employment, or the applicant to accept employment. An offer of employment, if made, is for employment at will and is not to be construed as a guarantee of continued employment. MSI, Inc. reserves the right to terminate the employment of any employee at any time. Any employee also has the right to terminate his or her employment with MSI, Inc. at any time. I authorize investigation of all matters contained in this application which MSI, Inc. may deem relevant to my employment and authorize my previous employers or other persons having information concerning me or my record to report such information to MSI, Inc. and such persons are hereby released from all liability for issuing such information. MSI, Inc. will keep all such information confidential except where such information is required to be released by law or order of a court or other authority. I understand and agree that I will be subject to immediate dismissal if it is subsequently discovered that the information herein is untrue or that I have failed to disclose a material fact. I understand that if employed by MSI, Inc. such employment will occur at will and no contract of employment, expressed or implied, is created and that no representative of MSI has any authority to enter into any agreement for employment of any specified period of time, or to make any agreement contrary to the foregoing. I understand that if I receive an offer of employment and I accept the position, I will be required to complete additional information necessary for company record keeping Page 4 of 6 v 0911
requirements. Notice to Applicants as Required by the Fair Credit Reporting Act As part of our employment process, an investigative consumer report, as governed by the Fair credit Reporting Act or any similar state or local statute, may be requested. However, requests will not be made without your prior written authorization. Notice to Applicants in California In answering this question do not include: Information regarding an arrest or detention that did not result in conviction. Information regarding referral to, and participation in, any pre-trial or pot-trial diversion program; minor traffic violations; convictions for which the record has been judicially ordered sealed or expunged; marijuana related convictions described in California labor Code Section 432.8 that are more than two years old; misdemeanor convictions for which probation has been successfully completed or discharged and that have been judicially dismissed pursuant to California Penal Code section 1203.4. DISCLOSURE REGARDING BACKGROUND INVESTIGATION Mace Security International ( MSI ) may request, for lawful employment purposes, background information about you from a consumer reporting agency in connection with your employment or application for employment (including independent contractor assignments, as applicable). This background information may be obtained in the form of consumer reports and/or investigative consumer reports (commonly known as background reports ). These background reports may be obtained at any time after receipt of your authorization and, if you are hired or engaged by the Company, throughout your employment or your contract period. AccuSource, a consumer reporting agency, will obtain the report for the Company. AccuSource is located at 1240 E. Ontario Avenue, suite 102-140, Corona, Ca 92881 and can be reached at (888) 649-6272. The types of information that may be obtained include, but are not limited to: social security number verifications; address history; cr history; criminal records and history; public court records; driving records; accident history; worker s compensation claims; bankruptcy filin history verifications (e.g., dates of attendance, degrees obtained); employment history verifications (e.g., dates of employment, sal reasons for termination, etc.); personal and professional references checks; professional licensing and certification checks; drug/alcoho and drug/alcohol history in violation of law and/or company policy; and other information bearing on your character, general repu characteristics, and mode of living and credit standing. You may request more information about the nature and scope of any investigative consumer reports by contacting the Company. A summary of your rights under the Fair Credit Reporting Act is also being provided to you. ADDITIONAL STATE LAW NOTICES If you are a California state applicant, employee or contractor, please also note: CALIFORNIA: Pursuant to section 1786.22 of the California Civil Code, you may contact AccuSource during normal business hours (9am to 5 pm PST, Monday through Friday) to obtain and review all information in your file. You may obtain such information by appearing in person at AccuSource offices, during normal business hours and upon reasonable notice, and upon submitting proper identification and paying the duplication costs. You may be accompanied by one other person, provided that person furnishes proper identification. You may also obtain a copy of your file by certified mail, if you have previously provided identification in a written request that your file be sent to you or a third party identified by you. You may also obtain a summary of your file by telephone, upon providing proper identification. AccuSource has trained personnel available to explain your file to you, including any coded information. AUTHORIZATION I have carefully read and understand this Disclosure and Authorization form and the attached summary of rights under the Fair Credit Reporting Act. By my signature below, I consent to preparation of background reports by a consumer reporting agency such as AccuSource, and to the release of such background reports to the MSI, Inc. and its designated representatives and agents, for the purpose of assisting the MSI, Inc. in making a determination as to my eligibility for employment (including independent contractor assignments, as applicable), promotion, retention or for other lawful employment purposes. I understand that if MSI, Inc. hires me or contracts for my services, my consent will apply, and the MSI, Inc. may obtain background reports, throughout my employment or contract Page 5 of 6 v 0911
period. I understand that information contained in my employment or contractor application, or otherwise disclosed by me before or during my employment or contract assignment, if any, may be used for the purpose of obtaining and evaluating background reports on me. I also understand that nothing herein shall be construed as an offer of employment or contract for services. I hereby authorize law enforcement agencies, learning institutions (including public and private schools and universities), information service bureaus, credit bureaus, record/data repositories, courts (federal, state and local), motor vehicle records agencies, my past or present employers, the military, and other individuals and sources to furnish any and all information on me that is requested by the consumer reporting agency. By my signature below, I also certify the information I provided on and in connection with this form is true, accurate and complete. I agree that this form in original, faxed, photocopied or electronic (including electronically signed) form, will be valid for any background reports that may be requested by or on behalf of MSI, Inc.. Signature: Date: California applicants only: Please check this box if you would like to receive (whenever you have such right under the applicable state law) a copy of your background report if one is obtained on you by MSI, Inc. Fax Completed Application to (440) 287-7020 or email to HR@mace.com Page 6 of 6 v 0911