Cox/TNT background

Tony Hagedorn - President

5660 W 32nd St, Sedalia MO 65301

(903)785-8000 (479)366-7730

FAX: (903)785-9887

Please return to us a copy of two forms of identification, Driver's License and Social Security Card. This is solely for your file held within the office.

If you do not have a Social Security Card, you will need to visit your local Social Security Administration office to request a replacement card.

Thank You,

TNT Cable Contractors, Inc.

Take Photo of DL*

Take Photo of SS card*

Drug Screen - Statement of Understanding

Tony Hagedorn - President

5660 W 32nd St, Sedalia MO 65301

(903)785-8000 (479)366-7730

Fax: (903)785-9887

I ____________________ understand that I must pass an initial drug screen test.

If contracted, I understand I may be subject to random drug screening and will be required to provide a clean sample at that time.

I further understand, that should I fail to provide a clean sample or fail to provide a sample at all, I will not be offered contract work with TNT Cable Contractors, Inc.

Name*

SIGNATURE*

DATE*

Date

Full Name*

First and Middle NameLast Name

Other Name(s) Used: (like Maiden)

Male*

Gender:Female

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Former Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Social Security Number*

Driver's License Number.*

State*

Date of Birth*

Date

Place of Birth*

(City, State, Country)

* This information will be used for purposes of background screening only and will not be used in making any employment decisions.

Employer ("the Company") may obtain information about you from a consumer reporting agency for employment purposes. Thus, you may be the subject of a "consumer report" and/or an "investigative consumer report" which may include information about your character, general reputation, personal characteristics, and/or mode of living, and which can involve personal interviews with sources such as your neighbors, friends, or associates, including motor vehicle record (or "driving record") checks, workers compensation records, credit bureau files, employment references, personal references, social networking (i.e. Facebook, Twitter), drug screening, any educational and licensing institution or military branch and to receive any criminal record information pertaining to you which may be in the files of any federal, state or local criminal justice agency in any state. Credit reports will only be requested where such information is substantially related to the duties and responsibilities of the position for which you are applying. These reports may be obtained at any time after receipt of your signed authorization and, if you are hired, throughout your employment. An "investigative consumer report" includes information from personal interviews, except in California where that term means any consumer report. have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope form of of You investigative consumer report and to request a copy of your report. Please be advised that the nature and scope of the most common any investigative consumer report obtained with regard to applicants for employment is an investigation into your education and/or employment history conducted by InfoMart, 1582 Terrell Mill Road, Marietta, GA 30067, 800-800-3774 www.infomart-usa.com or another outside organization. The of this disclosure and authorization is all-encompassing, however, allowing Employer to obtain from any outside organization all manner of scope consumer reports and investigative consumer reports now and, if you are hired, throughout the course of your employment to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report. New York and Maine applicants or employees only: You have the right to inspect and receive a copy of any investigative consumer report requested by Employer by contacting the consumer reporting agency identified directly above. You may also contact the Company to request the name, address and telephone number of the nearest unit of the consumer reporting agency designated to handle inquiries, which Employer shall provide within 5 days. if such report was requested, informed of the name and address of the consumer reporting agency that furnished the report. Oregon applicants or employees only: Information describing your rights under federal and Oregon law regarding consumer identity theft protection, the storage and disposal of your credit information, and remedies available should you suspect or find that Employer has not maintained secured records is available to you upon request. Washington State applicants or employees only: Under the Washington Fair Credit Reporting Act, you have the right to ask InfoMart for a disclosure of the nature and scope of the investigative consumer report Employer ordered, if any. If Employer obtains information bearing on your credit worthiness, credit standing or credit capacity, it will be used to evaluate whether you would present an unacceptable risk of theft or other dishonest behavior in the job for which you are being considered. Minnesota and Oklahoma applicants or employees only: Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Company.

Signature*

Date*

Date

Name*

Applicant Name: (First Middle Last)*

ACKNOWLEDGMENT AND AUTHORIZATION

I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of "consumer reports" and/or "investigative consumer reports" at any time after receipt of this Acknowledgement and Authorization and, if I am hired, throughout my employment. I understand that, except in California, InfoMart, 1582 Terrell Mill Road, Marietta, GA 30067 800.800.3774 www.infomart-usa.com, and its agents, and/or another outside organization acting on behalf of Employer, and/or Employer itself may rely on this authorization to order additional consumer reports, including investigative consumer reports, from time to time during my employment, as deemed necessary for employment purposes and as allowed by law. I also authorize the following agencies and entities to disclose to InfoMart and its agents, and/or another outside organization acting on behalf of Employer, and/or Employer itself, all information about or concerning me, including, but not limited to: my past or present employers; learning institutions, including colleges and universities; law enforcement and all other federal, state and local agencies; federal, state and local courts; the military; credit bureaus; insurance companies; testing facilities; motor vehicle records agencies; all other private and public sector repositories of information; and any other person, organization, or agency with any information about or concerning me. The information that can be disclosed includes, but is not limited to, information concerning my employment history, earnings history, education, credit history, motor vehicle history, criminal history, military service, drug testing results, and professional credentials and licenses. I agree that a facsimile ("fax") or photographic copy of this Acknowledgement and Authorization shall be as valid as the original. New York applicants or employees only: By signing below, you also acknowledge receipt of Article 23-A of the New York Correction Law. California applicants or employees only: By signing below, you also acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION AND CREDIT CHECKS PURSUANT TO CALIFORNIA LAW. Please check this box if you would like to receive a copy of an investigative consumer report or consumer credit report if one is obtained by the Company at no charge whenever you have a right to receive such a copy under California law.

Signature*

Date*

Date

Name*

APPLICANT'S DISCLOSURE & AUTHORIZATION FOR BACKGROUND SCREENING

DISCLOSURE REGARDING BACKGROUND INVESTIGATION

APPLICANT:

APPLICANT'S DISCLOSURE & AUTHORIZATION FOR BACKGROUND SCREENING