APPLICATION FOR EMPLOYMENT

Application for Employment
Applicants are considered for all positions without regard to race, sex, color, national origin, age, religion, handicap, or political affiliation.
Date of application:

MonthDayYear
Date
Position applied for
Last Name
First
MI
Social Security Number
Address
City
State, ZIP
County
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Emergency Number
Please enter a valid phone number.
Employment Status Section
Have you ever been employed by CRDC before?

YesNo
yes, give date If

MonthDayYear
Date
Position
Do you have transportation available? Proof of auto liability will be required if job requires travel.

YesNo
Can you travel if job requires it?

YesNo
May we contact your current employer?

YesNo
May we contact your former employer(s)?

YesNo
Nepotism
Do you have relatives that are currently employed with CRDC? If yes list: Name Relationship

YesNo
Do you have relatives that are currently employed with CRDC? If yes list: Name Relationship
Do you have relatives that are currently employed with CRDC? If yes list: Name Relationship
Do you have relatives that are employed through a contract with CRDC? If yes, list

YesNo
Name
Relationship
Do you have relatives that server on the Board of Directors of CRDC?*

YESNO
Name
Relationship
This information is required to ensure compliance with CRDC's Nepotism Policy.
References
List three (3) references who are not related to you, and who have knowledge of your work qualifications, and who are not current or previous employer(s
Name
Phone No.
Name
Phone No.
Name
Phone No.
Please read the following before signing application:the following before signing application:

Check your answers to make sure all questions have been completed properly. applying for requires a college degree or certification, a copy of your transcript, certificate or license may be required as a condition of employment.

I, the below-signed individual, hereby declare that the above information is true and factual. I understand that if I am hired my employment is for no definite period of time and I may be terminated at any time.

I understand that certain jobs may require the following as a condition of employment:

*An acceptable driver safety record

*Proof of the minimum liability coverage under Arkansas State Law

*A physician's statement stating that I am physically able to perform the job duties

*A negative pre-employment drug screen result

I understand that I will be required to provide proof of eligibility to work in the United States pursuant to the Immigration Reform and Control Act of 1986 as a condition of employment.

I understand that any false, misleading or incomplete statement could lead to my dismissal as an employee or rejection as an applicant.
Applicant Signature Type Here
Date

MonthDayYear
Date
Applications are valid for thirty (30} days
Educational History
Did you graduate from High School?

YesNo
If not, do you have a GED

YesNo
Elementary
Diploma/Degree
Course of Study
High School
Diploma/Degree
Course of Study
College/Univ.
Diploma/Degree
Course of Study
Grad/Professor
Diploma/Degree
Course of Study
List professional license(s) relevant to position(s) for which you are applying. Give type of license, license number, date of expiration and state:
List other experience that you believe would qualify you for employment with CRDC (self-employment, community activities, work with social or religious organizations, student leadership activities, etc.)
List any other skills or abilities you would like CRDC to be aware of.
Work History
List your prior work experience beginning necessary.

with your most recent employer.
Employer
Type of Business
Address
Address
Job Title
Specific Duties
Specific Duties
Supervisor
Phone Number
Current Salary
from Employed
to
Reason for Leaving
Employer
of Business Type
Address
Address
Title
Duties Specific
Phone Number
Current Salary
Current Salary
Supervisor
from Employed
to
Reason for Leaving
Employer
Type of Business
Type of Business
Address
Address
Job Title
Specific Duties
Supervisor
Phone Number
Current Salary
from Employed
to
Reason for Leaving
Applicant Release
I hereby authorize Crowley's Ridge Development Council, Inc. to inquire and ask former employers and references information regarding dates of work, quality of work, positions held, salary, attendance habits, workmanship, cooperation, willingness to rehire, reason for leaving, etc.

I do hereby release the mentioned individual companies or institutions, including Crowley's Ridge Development Council, Inc. from all liability for any damage whatsoever in furnishing and using such information.

I authorize a photocopy of this authorization to be furnished the aforementioned when asked for information relative to suitability for employment.
Applicant Signature Type name here
Date

MonthDayYear
Date
Crowley's Ridge Development Council (CRDC), Inc.
DISCLOSURE AND AUTHORIZATION FORM TO OBTAIN CONSUMER REPORTS FOR EMPLOYMENT PURPOSES
Please Read Carefully Before Signing the Authorization
DISCLOSURE
considering you for employment and, In are employed, in considering you for if yo u subsequent promotion, assignment, reassignment, retention, or discipline, Crowley's Ridge Development Council, Inc. ("the Company") may request and rely upon one or more consumer reports or investigative consumer reports about you that we obtain from a consumer reporting agency, such as lntelliCorp Records, Inc.
- a "consumer report" is a 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 for the purpose of serving as a factor in making part an employment-related decision about you. Such information may include, for example, credit information, criminal history reports, or driving records; and
- an "investigative consumer report" is a consumer report in which information on your character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with your prior employers, neighbors, friends, or associates, or with others who may have knowledge concerning any such items of information. In the event an investigative consumer report is requested about you, you are entitled to 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 ("FCRA"
the Under FCRA, before the Company can obtain a consumer report or investigative about yo consumer repo u for rt employment purposes, we must have your written whole or in part, of authorization. Before we take adverse action on the basis, in in th t information you will report, be provided a copy of that report, the name, address, a and telephone number of the consumer reporting agency, and a summary of your rights the FCRA. under
AUTHORIZATION
have read and understand the foregoing ure, and authorize the Company to Disclos obtain and rely upon consumer reports or investigative consumer reports in considering a for employment and, if me I subsequent promotion, m employed, in considering me for g assignment, reassinment, retention, or discipline. By my signature below, I authorize the Company to obtain any such reports and to share the information received with any person involved in the employment decision about me.
I do Employment and Reference Verifications
do not
authorize you to contact my current employer for

will authorize immediate inquiries to the Human Resources Department and to any (This listed supervisors or references in the Employment/Reference Section of your application

I a!so agree that this Disclosure and Authorization in original, faxed, photocopied, or electronic (including electronically signed) form will be valid for any consumer reports or investigative consumer reports that may be requested about me by or on behalf of the Company.
Applicant Signature Type name here
Date

MonthDayYear
Date
Personal Data
Name

First NameMiddle NameLast Name
Current Address
Dates Lived Here
Addresses for the Past Seven Years: (include street, city, state, zip code)
Addresses for the Past Seven Years: (include street, city, state, zip code)
Dates of Residence

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Other Names Used (inducting maiden name)
Years used
Social Security Number
Driver's License
State
Email address (may be used for official correspondence)
I have the right to make a request to lntelliCorp Records, Inc, upon proper t equest the nature and identification. to rall files on substance of information in its me a recipients of any the time of my request, including sources of information, and the reports on me which lntelliCorp Records, Inc has previously furnished within the two my request. year period preceding
I certify that all of elements othe person data I have provided are true, accurate and complete. I understand and agree that any omission, false statement, misleading statement, or answer made by me on my application or any supplements to it and in any interviews will be sufficient grounds for rejection of employment and my discharge after employment.
Printed Name
Applicant Signature (Type name here)
Date
Should be Empty:

Application for Employment

Employment Status Section

Nepotism

References

Educational History

Work History

Applicant Release

DISCLOSURE AND AUTHORIZATION FORM TO OBTAIN CONSUMER REPORTS FOR EMPLOYMENT PURPOSES

Please Read Carefully Before Signing the Authorization

DISCLOSURE

AUTHORIZATION

Personal Data