Employer 1

Employer 2

Employer 3

Employer 4

Employer 5

To your knowledge, do you have or have you ever had any of the following ailments?

Injury 1

Injury 2

Injury 3

Conviction 1

Conviction 2

I hereby declare that I am not disabled in any way which would prevent me from steadily performing all the work applied for in this application. I further declare that the answers to the questions on the opposite side are correct and that any misstatement of tact or omission should be cause for dismissal or rejection. I authorize the company to contact any of my previous employers as well as any reference source in order to verity the tacts and information I have furnished regarding my qualifications and character. I hereby authorize any person(s) having knowledge thereof to provide such information to the company, and I hereby release from liability and agree to hold harmless any person that furnishes such information in good faith. I agree that I will submit to a physical, polygraph, urinalysis, and/or blood or other examination requested by the company at any time prior to or subsequent to my employment. I authorize the company to supply my employment record in whole or in part and in confidence to any employer, insurance agency, or other party with a legal and proper interest, and I hereby release the company from any liability and agree to hold harmless any employee of the company who furnishes such information. I further understand that no employee or officer or agent of the company may bind it by oral or printed statements, including handbooks, benefit books, or bulletins, contrary to the above.

Under the provisions of the Fair Credit Reporting Act, 15 U.S.C. Sec. 1681, et seq. notice is hereby given that a consumer report or investigative consumer report may be made which may include information to your credit worthiness, character, general reputation, personal characteristics, and mode of living, which will be used for employment purposes. An investigation into your workers' compensation or industrial accident background may also be conducted. You are further advised under said Act that any person who procures or causes to be prepared an investigative consumer report on any consumer shall, upon written request made by the consumer within a reasonable period of time after the receipt by him/her of the disclosure required by subsection 1681 (d) shall make a complete and accurate disclosure of the nature and scope of the investigation requested. This disclosure shall be made in writing, mailed or otherwise delivered, to the consumer not later than five days after the date on which the request for such disclosure was received from the consumer or such report was first requested, whichever is the latter.

You are further advised that if you are denied employment, either wholly are partly, because of information contained in a consumer report as that term is defined in the Fair Credit reporting Act, that a disclosure will be made to you of the name and address of the consumer reporting agency making such a report.