TCM Application

Tri-County Maintenance, Inc.

P.O. Box 6038

Lynchburg, VA 24505

Application for Employment

All statements made by applicants for employment on this application form will be checked for accuracy. We offer equal employment opportunities to all persons without discrimination on the basis of race, color, religion, age, sex, national origin, citizenship status, physical or mental disability, or past, present, or future service in the Uniformed Services of the U.S., or any other légally protected status. The use of this form does not mean there are positions open and does not obligate us in any way.
Personal Information
Full Name*
Home or Nearest Phone*
Format: (000) 000-0000.
Emergency Phone Number*
Format: (000) 000-0000.
Social Security Number*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If at present address less than one year, please give previous address
YesNo
If no, employment is subject to verification that you are of minimum legal age.
YesNo
Examples: driver's license, Social Security card, birth certificate, and/or Immigration and Naturalization Service Documents
Employment Information
Position(s) applied for*
How soon could you report to work?*
Full-TimePart-TimeTemporary
Rate of Pay Expected
What days and hours if part-time?
Days
Hours (Number)
Hours From:

Hour Minutes

AM/PM Option
Hours To:

Hour Minutes

AM/PM Option
Education
Elementary/Middle
Name and Address of School
Courses Majored In
5678
Graduate? Show Degree
High School
Name and Address of School
Courses Majored In
9101112
Graduate? Show Degree
College
Name and Address of School
Courses Majored In
1234
Graduate? Show Degree
Post Graduate
Name and Address of School
Courses Majored In
Last Year Completed
Graduate? Show Degree
Further Information
YesNo
YesNo
Employee RefferalFormer EmployeeNewspaper AdHigh School RecruitmentCollege RecruitmentWalk-InOther
YesNo
YesNo
If you have been refused a bond, state reason and date.
YesNo
If yes, what branch?
Date Entered

MonthDayYear
Date
Date Discharged

MonthDayYear
Date
YesNo
If yes, state date, court, and place where offence occurred.
Previous Employment
YesNo
YesNo
YesNo
Why do you desire to make a change?*
YesNo
If yes, please explain.
YesNo
If yes, please explain.
Prior Work Record

Start with most recent or present employer and complete in full
Employer 1
Name and Address of Most Recent Employer
Telephone Number
Format: (000) 000-0000.
Immediate Supervisor (Name & Position)
Your Job Title and Position
Date Hired

MonthDayYear
Date
Date Left

MonthDayYear
Date
Starting Rate
Last Rate
Reasons for Leaving
YesNo
Employer 2
Name and Address of Former Employer
Telephone NumberTelephone
Format: (000) 000-0000.
Immediate Supervisor (Name and position)
Your Job Title and Position
Date Hired

MonthDayYear
Date
Date Left

MonthDayYear
Date
Starting Rate
Last Rate
Reasons for Leaving
YesNo
Employer 3
Name and Addreas of Former Employer
Telephone Number
Format: (000) 000-0000.
Immediate Supervisor (Name & Position)
Your Job Title and Position
Date Hired

MonthDayYear
Date
Date Left

MonthDayYear
Date
Starting Rate
Last Rate
Reason for Leaving
YesNo
Please provide any additional information such as special skills, training, experience, equipment operation or other qualifications you feel will be helpful in considering your application.
REFERENCES

Do Not List Relatives Or Former Employers
Name
Address
Telephone
Format: (000) 000-0000.
Name
Address
Telephone
Format: (000) 000-0000.
Name
Address
Telephone
Format: (000) 000-0000.
JOB APPLICANTS AGREEMENT AND CERTIFICATION
"I certify that the information given by me in this application is true in all respects, and I agree that if the information given is found to be false in any way, it shall be considered sufficient cause for denial of employment or discharge. I authorize the use of any information in this application to verify my statements, and I authorize employers,all references, and any other persons to answer all questions asked concerning my ability, character, reputation, and previous employment record. I past release all such persons from any liability or damages on account of having furnished such information."

"I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between the Company and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon the Company unless made in writing. If an employment relationship is established, I understand1 thathave theright to terminate my employment at any time and that the Company retains the same right."

"If I am offered employment, I agree to submit to a physical examination whenever requested, and I understand my becoming employed and/or my continued emplbyment are subject to the results of any physical examination related to my job duties in accordance with Company policies and procedures." "I understand that if employed, policies and rules which are issued are not conditions of employment and that the Company may revise policies and procedures. in whole or in part, at any time."

"I understand that this application will be kept on active file for 30 days from the date completed, after which time I would have to reapply in accordance with established Company procedures.
Signature of Applicant
Date

MonthDayYear
Date
NOTICE TO APPLICANTS
If you require an accommodation because of a physical or mental disability in order to participate in any phase of the application process, please make that fact known to the individual processing your application.

If you are required to take any pre-employment screening tests, and you require an accommodation because of a physical or mental disability to enable you to take or successfully complete such a test, please make that fact knownin advance to the test administrator.

If an offer of employment is made and, because of a physical or mental disability, you will need an accommodation to perform any essential job function, please make that fact known to the individual processing your application.
APPLICANT AGREEMENT
If an offer of employment is made, I agree to submit to a medical examination, including a drug test, and understand that my subsequent employment will be contingent on the results of the medical examination and drug test.

I understand that the examining physician may ask questions regarding my current health condition, health history, health insurance claim and workers' compensation claim history and that all such information will be retained by the examining physician in his/her confidential medical files, to be released only in accordance with Federal and State law.

I also understand that falsification of any such information that I furnish could result in termination of my employment, if hired.
Signature
Date

MonthDayYear
Date
EMPLOYMENT INQUIRY RELEASE
In conjunction with my application for employment (including contract services) with you, my prospective employer, I understand that you intend to hire Selection.com to obtain Consumer Reports and/or Investigative Consumer Reports (hereinafter called "Reports") about me as defined in the Fair Credit Reporting Act (FCRA). These "Reports" may include information concerning my credit worthiness, credit standing, credit capacity, character, academic background, credentials, work habits, work performance, work experience, reasons for work termination, general reputation, person characteristics or mode of living. You also may seek information concering my employment history, workers compensation history, motor vehicle record, education backgroun, civil litigation history and/or criminal record.

I understand that you may rely on any or all of the above referenced information in determining whether to extend an offer of employment to me. If you contemplate making an adverse employment-related decision that will affect me based, in whole or in part, upon an "Report" obtained from Selection.com, I will be provided with a copy of the "Report" and a written summary of my Consumer Rights under the FCRA before you finalize that decision.

I have read the above disclosure and I hereby authorize you, Selection.com, or its authorized agents to obtain the above referenced information about me. I also authorize all agencies, bureaus, employers, information service organizations and individuals to provide any of the above referenced knowledge or information thay have concerning me. If I am hired, this authorization shall remain on file and shall serve as an ongoing authorization for you to obtain "Reports" about me from Selection.com at any time during my employment with you. A photocopy of facsimile of this authorization shall be as valid as the original. I agree that any and all disputes arising from this "Report" shall be brought only in state or federal court in the state of Ohio and shall be governed by, and construed in accordance with, the laws of the State of Ohio.
Signature
Date

MonthDayYear
Date
THE FOLLOWING INFORMATION IS REQUIRED TO CONDUCT THE BACKGROUND INVESTIGATION
Name*

First NameLast Name
Middle Initial*
Social Security Number*
PREVIOUS OR MAIDEN NAME (if applicable)
PHONE NUMBER*
Format: (000) 000-0000.
STREET ADDRESS*
CITY*
STATE*
ZIP*
DRIVER'S LICENSE NUMBER*
EMAIL ADDRESS*
example@example.com
STATE ISSUED*
List states and counties of residence, other than above, for the past seven (7) years:
COUNTY
STATE
COUNTY
STATE
COUNTY
STATE
FOR IDENTIFICATION PURPOSES ONLY: Date of birth*

MonthDayYear
Date
My prospective employer undersands age to be a protected characteristic and the information requested will not be used as the basis for any employment decision.
Yes
Email adress
example@example.com
By entering my email address, I authorize Selection.com to deliver my Report via email.
Notice to California Residents: Under section 1766.22 of the California Civil Code, you may view the file maintained on you by Selection.com during normal business hours. You may also obtain a copy of this file, either in person or by mail, by submitting proper identification and paying the costs of duplication services. You may also receive a summary of the file by telephone by being able to provide adequate identification as to allow Selection.com to determine with reasonable certainty that you are the subject of the report. Selection.com is required to have personnel available to explain your file to you and must explain to you any coded information appearing in your file. If you appear in person, another person of your choice may accompany you, providing that this additional person furnishes proper identification. Selection.com's Privacy Policy can be viewed at www.selection.com
IF FAXING OR EMAILING REQUEST, THIS SECTION MUST BE COMPLETED BY EMPLOYER FOR PROCESSING
Customer Number
Location or Store Number
Date Submitted

MonthDayYear
Date
Contact Person
Phone Number
Format: (000) 000-0000.
Position Applied For
Combined Report
Individual Reports
Yes
It Yes, Enter County(s) and state(s)
Other.
This Form Provided By: Selection.com 155 Tri County Boulevard; Suite 150 Cincinnati, OH 45246

Telephone - 800. 325. 3609

Fax - 888.767.2435
Should be Empty:

Tri-County Maintenance, Inc.

P.O. Box 6038

Lynchburg, VA 24505

Application for Employment

Personal Information

Employment Information

What days and hours if part-time?

Education

Elementary/Middle

High School

College

Post Graduate

Further Information

Previous Employment

Prior Work Record

Employer 1

Employer 2

Employer 3

REFERENCES

JOB APPLICANTS AGREEMENT AND CERTIFICATION

NOTICE TO APPLICANTS

APPLICANT AGREEMENT

EMPLOYMENT INQUIRY RELEASE

THE FOLLOWING INFORMATION IS REQUIRED TO CONDUCT THE BACKGROUND INVESTIGATION

List states and counties of residence, other than above, for the past seven (7) years:

IF FAXING OR EMAILING REQUEST, THIS SECTION MUST BE COMPLETED BY EMPLOYER FOR PROCESSING