ATLANTIC CONTRACTING COMPANY INC. APPLICATION FOR EMPLOYMENT

ATLANTIC CONTRACTING COMPANY INC. APPLICATION FOR EMPLOYMENT

AN EQUAL OPPORTUNITY EMPLOYER - Active For Ninety (90) Days Only
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 regard to race. color, religion, age* marital of veteran’s status, sex, national origin, disability, or any other legally protected status.
Position Applying For*
Date of Application*

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Referred by
Name*

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Phone Number*

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Email*
example@example.com
Current Residence*

Street Address

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Emergency Contact Name*

First NameLast Name
Emergency Contact Number*

Area CodePhone Number

Education
Elementary School

Name of SchoolGraduated?Last Completed Year?
High School

Name of SchoolGraduated?Last Completed Year?
College

Name of SchoolGraduated?Last Completed Year?
PRIOR WORK RECORD

(Start with most recent or present employer and complete in full)
Recent Employer
Recent Employer*
Name
Address of Most Recent Employer*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisors Name*

First NameLast Name
Date Hired*
Starting Rate*
Date Left*
Last Rate*
Reason for Leaving*
May we contact this employer?*

YesNo
Employer Phone Number*

Area CodePhone Number
Recent Employer #2
Recent Employer #2
Name
Address of Most Recent Employer #2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisors #2 Name

First NameLast Name
Date Hired
Starting Rate
Date Left
Last Rate
Reason for Leaving
May we contact this employer?

YesNo
Employer Phone Number

Area CodePhone Number
Recent Employer #3
Recent Employer #3
Name
Address of Most Recent Employer #3

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisors #3 Name

First NameLast Name
Date Hired
Starting Rate
Date Left
Last Rate
Reason for Leaving
May we contact this employer?

YesNo
Employer Phone Number

Area CodePhone Number
Please provide any additional information such as special skills, training, cashier experience, management experience, equipment operation, or qualifications you feel will be helpful to us in considering your application.

References

Do not list relatives or former employers
Reference 1 Name

First NameLast NameSuffix
Reference 1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reference 1 Phone Number

Area CodePhone Number
Reference 2 Name

First NameLast NameSuffix
Reference 2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reference 2 Phone Number

Area CodePhone Number
Reference 3 Name

First NameLast NameSuffix
Reference 3 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reference 3 Phone Number

Area CodePhone Number

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 the past employers, all references, and any other persons to answer all questions asked concerning my ability, character, reputation, criminal record, driving record, credit history and previous employment record. I release all such persons from any liability or damages on account of having furnished such information.

In processing this employment application, Atlantic Contracting Company, Inc. may request that an investigative report be prepared. This report may include information as to my character, general reputatton, credit history, driving record, criminal record and previous employment record. I understand that I have the right to request that Atlantic Contracting Company, Inc. completely and accurately disclose to me the nature and scope of such an investigation, if I make request to the Company's Human Resources Department within
a reasonable time after completing this application.

I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between Atlantic Contracting Company, Inc. 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 Atlantic Contracting Compnay, Inc. unless made in writing. If an employment relationship is established, I understand that my employment would be at will-Atlantic Contracting Company, Inc. would have the right to terminate my employment without prior notice at any time either with or without cause.

I understand that prior to being offered employment with Atlantic Contracting Company, Inc. I may be requested to take an examination. ln the event I have a disability which will affect my ability to take the test, l will so inform Atlantic Contracting Company, Inc. prior to the administration of the test so that a reasonable accommodation can be made. Requested accommodations may include accessible testing sites, modified testing conditions, and accessible testing formats. Atltantic Contracting Company, Inc. reserves the right to require medical documentation concerning the need for the accommodation. I further understand that if an offer of employment is tentatively made to me, it is conditioned upon my successful completion of a medical examination.

I understand that if employed, policies and rules which are issued are not contracts of employment and that Atlantic Contracting Company, Inc. retains the sole discretion to adopt, rescind, revise or modify employee benefits, policies or procedures, in whole or in part, at any time without prior notice.

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*

Clear
Date*

MonthDayYear
Date

To:        All ACCI Employees and Potential Employees

From:    Niveen Kattan

RE:    Employee Survey - Request for Voluntary EEO Self-Identification

DATE:    January 1, 2010

Atlantic Contracting Company, Inc. is an equal opportunity/affirmative action employer. We are required to keep records on the race, sex, and ethnicity of our employees and to file periodic reports with the government. We recognize that some employees might find this intrusive and we regret giving any offense. The government does permit that the malcing or verifying of this information in employee records may be accomplished by what the government refers to as a "visual survey" by the employer. However, we prefer to give employees the opportunity to participate in a voluntary self-identification survey. We think selfidentification is likely to result in more accurate information. Nevertheless, self-identification is voluntary and there will be no negative consequences if you elect not to disclose this information. This information is kept confidential.

Atlantic Contracting Company, Inc. does not discriminate on the basis of race, color, religion, sex, national origin, age, or disability. Atlantic Contracting Company, Inc. malces all employment decisions on the basis of job related criteria. All information that is disclosed on the attached form, nor refusal to disclose this information, will not affect any decision having to do with hiring, re-hiring, transfer, promotion, compensation, training, benefits, continuation of employment, or any other employment practice.
EEO SELF- IDENTIFICATION FORM FOR ATLANTIC CONTRACTING COMPANY, INC. EMPLOYEES
It is necessary that you complete the data above the double line. Other information is voluntary and is disclosed or not disclosed according to the terms of the attached memorandum.
EMPLOYEE NAME*
EMPLOYEE ID#
POSITION*
WORK LOCATION / DEPARTMENT #*
PART I - Sex, Race and Ethnicity
The following designations are those cunently required by the Federal government. Please mark only one sex and one race/ethnic group.
Check One Only*

MaleFemale
Check One Only*

White, not of Hispanic Origin (includes persons of Middle Eastern descent)Black, not of Hispanic Origin (includes Jamaican and West Indian)Hispanic ( all races) (includes Mexican, Puerto Rican, Cuban, Central or South American or Spanish culture or origin)Asian or Pacific Islander (includes persons having origins in the Far East, Southeast Asia, the Indian subcontinent or the Pacific Islands)American Indian, Eskimo or Aleut (persons having origins in the original peoples of North America who maintain a cultural identification through tribal affiliation or community recognition)Decline to disclose

ATLANTIC CONTRACTING COMPANY INC

P.O. Box 49559 GREENSBORO, NC 27419 PHONE: 336-931-3109 FAX: 336-931-3108
Fair Credit Reporting Act Disclosure & Authorization

DISCLOSURE

In considering you as an applicant for employment or as a current employee, we may choose to secure and use information contained in either a consumer report or investigative consumer report about you obtained from a consumer reporting agency when: (1) considering your application for employment (2) making a decision whether to offer you employment, (3) deciding whether to continue your employment or (4) making other employment-related decisions directly affecting you.

For explanation purposes, a "consumer reporting agency" is a person or business that, on a cooperative nonprofit basis, or for monetary fees or dues, regularly assembles or evaluates consumer credit information or other information on consumers for a person who has a legitimate business need for the information or intends to use the information for employment purposes.

A "consumer report" means any written, oral or other communication of any information by a consumer reporting agency bearing on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living which is used or expected to be used or collected in whole or in part for the purpose of serving as a factor in establishing your eligibility for employment purposes.

An "investigative consumer report" means a consumer report or opinion thereof in which information on your character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with your neighbors, friends, or associates reported on or with others with whom you are acquainted or who may have knowledge concerning any such items of information.

In the event an investigative consumer report is prepared, you may request additional disclosures regarding the nature and scope of the investigation requested as well as a written summary of your rights under the Fair Credit Reporting Act.

AUTHORIZATION

By your signature below, you hereby authorize us to obtain a consumer report and / or an investigative report about you in order to consider you for employment. If hired, this authorization shall remain on file and shall serve as an ongoing authorization for us to procure consumer reports at any time during the employment period.
Signature*

Clear
Today's Date*

MonthDayYear
Date
Your Name*

First NameLast NameSuffix
PO Box 49559 Greensboro, NC 27419 Tel: (336) 931-3109 Fax: (336) 931-3108

MVR CHECK PERMISSION SLIP
I understand that all employees who operate a company vehicle must have a good driving record. I hereby authorize release of my driving record to the management of Atlantic Contracting Co., Inc.

I release the company, its employees, management, and designated representatives from all claims or causes of action resulting from the report and any decisions resulting therefrom.
Name

First NameLast NameSuffix
Signature

Clear
Today's Date

MonthDayYear
Date
Drivers License Number
State of Issue
Date of Birth

MonthDayYear
Date

Authorization to Obtain Records and Other Information for Employment Purposes
Name

First NameMiddle NameLast NameSuffix
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Address 1

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Address 2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
WAIVER
I hereby authorize Capital Associated Industries Services Corporation (CAI) to prepare a consumer report that will include my present and previous employment information, including salary as well as work performance. I also authorize CAI to verify my past and present driving records, education records, credit history, professional credentials, and other records as may be appropriate. I further authorize CAI to perform a criminal records search.

The facts set forth in my application for employment are true and complete. I understand that if employed, any false statement or omission of information on my application form may result in my termination. I further understand that this application is not intended to be a contract of employment, nor does this application serve as an obligation in any way to employ me or not to employ me.

I hereby fully waive any rights or claims that I have or may have against all current and/or former employers, and their agents, employees, and representative and damages that may directly or indirectly result from the use, disclosure, or release of any information by any person or party, whether such information is favorable or unfavorable to me. I further waive any claim against you and any outside agency utilized by you as a result of any information which is obtained in this investigation.
California, Minnesota, and Oklahoma residents only:
I want to receive a free copy of any Consumer Report, Investigative Consumer Report or Credit Report on me that is requested.*

YesNo
New York employers and residents only: By signing this consent form I acknowledge receipt of a copy of Article 23-A of New York Corrections Law.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

ATLANTIC CONTRACTING COMPANY INC. APPLICATION FOR EMPLOYMENT

Education

PRIOR WORK RECORD

Recent Employer

Recent Employer #2

Recent Employer #3

References

JOB APPLICANTS AGREEMENT AND CERTIFICATION

EEO SELF- IDENTIFICATION FORM FOR ATLANTIC CONTRACTING COMPANY, INC. EMPLOYEES

ATLANTIC CONTRACTING COMPANY INC

MVR CHECK PERMISSION SLIP

Authorization to Obtain Records and Other Information for Employment Purposes

WAIVER