APPLICATION FOR EMPLOYMENT
(Pre-Employment Questionnaire) (An Equal Opportunity Employer)
PERSONAL INFORMATION
SOCIAL SECURITY
NUMBER
NAME
LAST
FIRST
MIDDLE
STREET
CITY
STATE
ZIP
STREET
CITY
STATE
ZIP
Yes u
LAST
DATE
No u
PRESENT ADDRESS
PERMANENT ADDRESS
PHONE NO.
ARE YOU 18 YEARS OR OLDER?
ARE YOU PREVENTED FROM LAWFULLY BECOMING EMPLOYED
IN THIS COUNTRY BECAUSE OF VISA OR IMMIGRATION STATUS?
Yes u
No u
EMPLOYMENT DESIRED
DATE YOU
CAN START
SALARY
DESIRED
ARE YOU EMPLOYED NOW?
IF SO MAY WE INQUIRE
OF YOUR PRESENT EMPLOYER?
EVER APPLIED TO THIS COMPANY BEFORE?
WHERE?
FIRST
POSITION
WHEN?
REFERRED BY
EDUCATION
NAME AND LOCATION OF SCHOOL
*NO OF
YEARS
ATTENDED
*DID YOU
GRADUATE?
SUBJECTS STUDIED
GRAMMAR SCHOOL
MIDDLE
HIGH SCHOOL
COLLEGE
TRADE, BUSINESS OR
CORRESPONDENCE
SCHOOL
GENERAL
SUBJECTS OF SPECIAL STUDY OR RESEARCH WORK
SPECIAL SKILLS
ACTlVITIES: (CIVIC ATHLETIC ETC.)
EXCLUDE ORGANIZATIONS, THE NAME OF WHICH INDICATES THE RACE, CREED. SEX. AGE, MARITAL STATUS, COLOR OR NATION OF ORIGIN OF ITS MEMBERS.
U. S MILITARY OR
NAVAL SERVICE
RANK
PRESENT MEMBERSHIP IN
NATIONAL GUARD OR RESERVES
*This form has been revised to comply with the provisions of the Americans with Disabilities Act
and the final regulations and interpretive guidance promulgated by the EEOC on July 26. 1991.
TOPS FORM 3285 (92-8)
(CONTINUED ON OTHER SIDE)
LITHO IN U.S.A.
FORMER EMPLOYERS (LIST BELOW LAST THREE EMPLOYERS, STARTING WITH LAST ONE FIRST).
DATE
MONTH AND YEAR
NAME AND ADDRESS OF EMPLOYER
SALARY
POSITION
REASON FOR LEAVING
FROM
TO
FROM
TO
FROM
TO
FROM
TO
WHICH OF THESE JOBS DlD YOU LIKE BEST?
WHAT DlD YOU LIKE MOST ABOUT THIS JOB?
REFERENCES: GIVE THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR.
NAME
ADDRESS
YEARS
ACQUAINTED
BUSINESS
1
2
3
THE FOLLOWING STATEMENT APPLIES IN: MARYLAND & MASSACHUSETTS. [Fill in name of state.)
IT IS UNLAWFUL IN THE STATE OF ________________________ TO REQUIRE OR ADMINISTER A LIE DETECTOR TEST
AS A CONDITION OF EMPLOYMENT OR CONTINUED EMPLOYMENT. AN EMPLOYER WHO VIOLATES THIS LAW SHALL
BE SUBJECT TO CRIMINAL PENALTIES AND CIVIL LIABILITY.
Signature of Applicant
IN CASE OF
EMERGENCY NOTIFY
NAME
ADDRESS
PHONE NO.
"I CERTIFY THAT ALL THE INFORMATION SUBMITTED BY ME ON THIS APPLICATION IS TRUE AND COMPLETE, AND I UNDERSTAND THAT
IF ANY FALSE INFORMATION, OMISSIONS, OR MISREPRESENTATIONS ARE DISCOVERED, MY APPLICATION MAY BE REJECTED AND, IF I
AM EMPLOYED. MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME.
IN CONSIDERATION OF MY EMPLOYMENT, I AGREE TO CONFORM TO THE COMPANY'S RULES AND REGULATIONS, AND I AGREE THAT
MY EMPLOYMENT AND COMPENSATION CAN BE TERMINATED, WITH OR WITHOUT CAUSE. AND WITH OR WITHOUT NOTICE, AT ANY
TIME, AT EITHER MY OR THE COMPANY'S OPTION. I ALSO UNDERSTAND AND AGREE THAT THE TERMS AND CONDITIONS OF MY
EMPLOYMENT MAY BE CHANGED, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, AT ANY TIME BY THE COMPANY. I
UNDERSTAND THAT NO COMPANY REPRESENTATIVE, OTHER THAN IT'S PRESIDENT, AND THEN ONLY WHEN IN WRONG AND SIGNED
BY THE PRESIDENT, HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIC PERIOD OF TIME,
OR TO MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING.
DATE
SIGNATURE
DO NOT WRITE BELOW THIS LINE
INTERVIEWED BY:
DATE:
REMARKS:
NEATNESS
ABILITY
HIRED: u Yes u No
POSITION
SALARY/WAGE
APPROVED:
DEPT.
DATE REPORTING TO WORK
1.
EMPLOYMENT MANAGER
2.
3
DEPT. HEAD
GENERAL MANAGER
This form has been designed to strictly comply with State and Federal fair employment practice laws prohibiting employment discrimination. This Application for Employment Form
is sold for general use throughout the United States. TOPS assumes no responsibility for the inclusion in said form of any questions which, when asked by the Employer of the
Job Applicant, may violate State and/or Federal Law.
We welcome your application for employment at Southern Platte Fire Protection
District (hereinafter referred to as the Company). We are proud that our success
is the result of the quality and caliber of our employees. In pursuit of excellence,
we require, as a condition of employment, all applicants must consent to and
authorize a pre-employment verification of the background information
submitted on their applications and resumes.
The following information is used for identification
purposes in verifying background information.
Printed Name______________________ Date__________
Signature________________________________________
SS#____________________________________________
List any cities and states where you previously resided:
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
DISCLOSURE
AND
AUTHORIZATION
[IMPORTANT
-‐-‐
PLEASE
READ
CAREFULLY
BEFORE
SIGNING
AUTHORIZATION]
DISCLOSURE
REGARDING
BACKGROUND
INVESTIGATION
Southern Platte Fire Protection District
(“the
Company”)
may
obtain
information
about
you
for
employment
purposes
from
a
third
party
consumer
reporting
agency.
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.
These
reports
may
contain
information
regarding
your
credit
history,
criminal
history,
social
security
number
validation,
motor
vehicle
records
(“driving
records”),
verification
of
your
education
or
employment
history,
or
other
background
checks.
Credit
history
will
only
be
requested
where
such
information
is
substantially
related
to
the
duties
and
responsibilities
of
the
position
for
which
you
are
applying.
You
have
the
right,
upon
written
request
made
within
a
reasonable
time,
to
request
whether
a
consumer
report
has
been
requested
and
compiled
about
you,
and
disclosure
of
the
nature
and
scope
of
any
investigative
consumer
report
and
to
request
a
copy
of
your
report.
Please
be
advised
that
the
nature
and
scope
of
the
most
common
form
of
investigative
consumer
report
obtained
with
regard
to
applicants
for
employment
is
an
investigation
into
your
education
and/or
employment
history
conducted
by
Validity
Screening
Solutions,
PO
Box
860443,
Shawnee,
KS
66286-‐0443,
866.915.0792,
www.validityscreening.com,
or
another
outside
organization.
The
scope
of
this
notice
and
authorization
is
all-‐encompassing,
however,
allowing
the
Company
to
obtain
from
any
outside
organization
all
manner
of
consumer
reports
and
investigative
consumer
reports
now
and
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
Southern Platte Fire Protection District
by
contacting
the
consumer
reporting
agency
identified
above
directly.
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
the
Company
shall
provide
within
5
days.
New
York
applicants
or
employees
only:
Upon
request,
you
will
be
informed
whether
or
not
a
consumer
report
was
requested
by
Southern Platte Fire Protection District ,
and
if
such
report
was
requested,
informed
of
the
name
and
address
of
the
consumer
reporting
agency
that
furnished
the
report.
By
signing
below,
you
also
acknowledge
receipt
of
Article
23-‐A
of
the
New
York
Correction
Law.
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
the
Company
has
not
maintained
secured
records
is
available
to
you
upon
request.
Washington
State
applicants
or
employees
only:
You
also
have
the
right
to
request
from
the
consumer
reporting
agency
a
written
summary
of
your
rights
and
remedies
under
the
Washington
Fair
Credit
Reporting
Act.
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”
by
the
Company
at
any
time
after
receipt
of
this
authorization
and
throughout
my
employment,
if
applicable.
To
this
end,
I
hereby
authorize,
without
reservation,
any
law
enforcement
agency,
administrator,
state
or
federal
agency,
institution,
school
or
university
(public
or
private),
information
service
bureau,
employer,
or
insurance
company
to
furnish
any
and
all
background
information
requested
by
Validity
Screening
Solutions,
PO
Box
860443,
Shawnee,
KS
66286-‐0443,
866.915.0792,
www.validityscreening.com,
another
outside
organization
acting
on
behalf
of
the
Company,
and/or
the
Company
itself.
I
agree
that
a
facsimile
(“fax”),
electronic
or
photographic
copy
of
this
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.
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.
(Must
include
email
address:
California
applicants
or
employees
only:
By
signing
below,
you
also
acknowledge
receipt
of
the
NOTICE
REGARDING
BACKGROUND
INVESTIGATION
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
at
no
charge
if
one
is
obtained
by
the
Company
whenever
you
have
a
right
to
receive
such
a
copy
under
California
law.
www.validityscreening.com/Site/PrivacyPolicy
)
(Must
include
email
address:
Signature:
Last
Name
BACKGROUND
INFORMATION
Date:
First
Other
Names/Alias
Date
of
Birth
(mm/dd/yyyy)
Present
Address
[1][2]
Driver’s
License
#
Middle
[2]
Social
Security
#
[1][2]
[2]
State
of
Driver’s
License
Telephone
#
(Primary)
City/State/Zip
[1]
[2]
This
information
will
be
used
for
background
screening
purposes
only
and
will
not
be
used
as
hiring
criteria.
In
Utah,
this
information
may
only
be
collected
a)
when
extending
a
conditional
offer
of
employment
or
b)
at
the
time
the
background
report
will
be
run.
3
V
1.0
(Issued:
November
2012)
Para información en español, visite www.consumerfinance.gov/learnmore o escribe a la
Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.
A Summary of Your Rights Under the Fair Credit Reporting Act
The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of
information in the files of consumer reporting agencies. There are many types of consumer
reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell
information about check writing histories, medical records, and rental history records). Here is
a summary of your major rights under the FCRA. For more information, including information
about additional rights, go to www.consumerfinance.gov/learnmore or write to: Consumer
Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.
• You must be told if information in your file has been used against you. Anyone who uses a
credit report or another type of consumer report to deny your application for credit, insurance,
or employment – or to take another adverse action against you – must tell you, and must give
you the name, address, and phone number of the agency that provided the information.
• You have the right to know what is in your file. You may request and obtain all the
information about you in the files of a consumer reporting agency (your “file disclosure”). You
will be required to provide proper identification, which may include your Social Security
number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:
• a person has taken adverse action against you because of information in your credit report;
• you are the victim of identity theft and place a fraud alert in your file;
• your file contains inaccurate information as a result of fraud;
• you are on public assistance;
• you are unemployed but expect to apply for employment within 60 days.
In addition, all consumers are entitled to one free disclosure every 12 months upon request
from each nationwide credit bureau and from nationwide specialty consumer reporting
agencies. See www.consumerfinance.gov/learnmore for additional information.
• You have the right to ask for a credit score. Credit scores are numerical summaries of your
credit-worthiness based on information from credit bureaus. You may request a credit score
from consumer reporting agencies that create scores or distribute scores used in residential
real property loans, but you will have to pay for it. In some mortgage transactions, you will
receive credit score information for free from the mortgage lender.
• You have the right to dispute incomplete or inaccurate information. If you identify
information in your file that is incomplete or inaccurate, and report it to the consumer
reporting agency, the agency must investigate unless your dispute is frivolous. See
www.consumerfinance.gov/learnmore for an explanation of dispute procedures.
• Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable
information. Inaccurate, incomplete or unverifiable information must be removed or
corrected, usually within 30 days. However, a consumer reporting agency may continue to
report information it has verified as accurate.
• Consumer reporting agencies may not report outdated negative information. In most
cases, a consumer reporting agency may not report negative information that is more than
seven years old, or bankruptcies that are more than 10 years old.
• Access to your file is limited. A consumer reporting agency may provide information about
you only to people with a valid need – usually to consider an application with a creditor,
insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for
access.
• You must give your consent for reports to be provided to employers. A consumer reporting
agency may not give out information about you to your employer, or a potential employer,
without your written consent given to the employer. Written consent generally is not required
in the trucking industry. For more information, go to www.consumerfinance.gov/learnmore.
• You may limit “prescreened” offers of credit and insurance you get based on information in
your credit report. Unsolicited “prescreened” offers for credit and insurance must include a
toll-free phone number you can call if you choose to remove your name and address from the
lists these offers are based on. You may opt-out with the nationwide credit bureaus at 1-888567-8688.
• You may seek damages from violators. If a consumer reporting agency, or, in some cases, a
user of consumer reports or a furnisher of information to a consumer reporting agency
violates the FCRA, you may be able to sue in state or federal court.
• Identity theft victims and active duty military personnel have additional rights. For more
information, visit www.consumerfinance.gov/learnmore.
States may enforce the FCRA, and many states have their own consumer reporting laws.
In some cases, you may have more rights under state law. For more information, contact
your state or local consumer protection agency or your state Attorney General. For
information about your federal rights, contact:
TYPE OF BUSINESS:
1.a. Banks, savings associations, and credit unions with total assets of
over $10 billion and their affiliates.
b. Such affiliates that are not banks, savings associations, or credit
unions also should list, in addition to the CFPB
CONTACT:
a. Consumer Financial Protection Bureau
1700 G Street NW
Washington, DC 20552
b. Federal Trade Commission: Consumer Response Center – FCRA
Washington, DC 20580
(877) 382-4357
2. To the extent not included in item 1 above:
a. National banks, federal savings associations, and federal branches
and federal agencies of foreign banks
a. Office of the Comptroller of the Currency
Customer Assistance Group
1301 McKinney Street, Suite 3450
Houston, TX 77010-9050
b. State member banks, branches and agencies of foreign banks (other
than federal branches, federal agencies, and Insured State Branches of
Foreign Banks), commercial lending companies owned or controlled
by foreign banks, and organizations operating under section 25 or 25A
of the Federal Reserve Act
b. Federal Reserve Consumer Help Center
P.O. Box 1200
Minneapolis, MN 55480
c. Nonmember Insured Banks, Insured State Branches of Foreign
Banks, and insured state savings associations
c. FDIC Consumer Response Center
1100 Walnut Street, Box #11
Kansas City, MO 64106
d. Federal Credit Unions
d. National Credit Union Administration
Office of Consumer Protection (OCP)
Division of Consumer Compliance and Outreach (DCCO)
1775 Duke Street
Alexandria, VA 22314
Asst. General Counsel for Aviation Enforcement & Proceedings
Aviation Consumer Protection Division
Department of Transportation
1200 New Jersey Avenue, S. E.
Washington, DC 20590
Office of Proceedings, Surface Transportation Board
Department of Transportation
395 E Street, S.W.
Washington, DC 20423
Nearest Packers and Stockyards Administration area supervisor
3. Air carriers
4. Creditors Subject to Surface Transportation Board
5. Creditors Subject to Packers and Stockyards Act. 1921
6. Small Business Investment Companies
7. Brokers and Dealers
8. Federal Land Banks, Federal Land Bank Associations, Federal
Intermediate Credit Banks, and Production Credit Associations
9. Retailers, Finance Companies, and All Other Creditors Not Listed
Above
(Updated: November 2012)
Associate Deputy Administrator for Capital Access
United States Small Business Administration
406 Third Street, SW, 8th Floor
Washington, DC 20416
Securities and Exchange Commission
100 F St, N.E.
Washington, DC 20549
Farm Credit Administration
1501 Farm Credit Drive
McLean, VA 22102-5090
FTC Regional Office for region in which the creditor operates or
Federal Trade Commission: Consumer Response Center – FCRA
Washington, DC 20580
(877) 382-4357
Para información en español, visite www.consumerfinance.gov/learnmore o escribe a la
Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.
Remedying the Effects of Identity Theft
You are receiving this information because you have notified a consumer reporting
agency that you believe you are a victim of identity theft. Identity theft occurs when someone
uses your name, Social Security number, date of birth, or other identifying information,
without authority, to commit fraud. For example, someone may have committed identity
theft by using your personal information to open a credit card account or get a loan in your
name. For more information, visit www.consumerfinance.gov/learnmore or write to:
Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.
The Fair Credit Reporting Act (FCRA) gives you specific rights when you are, or believe
that you are, the victim of identity theft. Here is a brief summary of the rights designed to help
you recover from identity theft.
1.
You have the right to ask that nationwide consumer reporting agencies place
“fraud alerts” in your file to let potential creditors and others know that you may
be a victim of identity theft. A fraud alert can make it more difficult for someone to get
credit in your name because it tells creditors to follow certain procedures to protect you. It also
may delay your ability to obtain credit. You may place a fraud alert in your file by calling just one
of the three nationwide consumer reporting agencies. As soon as that agency processes your
fraud alert, it will notify the other two, which then also must place fraud alerts in your file.
•
•
•
Equifax: 1.888.766.0008; www.equifax.com
Experian: 1.888.397.3742; www.experian.com
TransUnion: 1.800.680.7289; www.transunion.com
An initial fraud alert stays in your file for at least 90 days. An extended alert stays in your file for
seven years. To place either of these alerts, a consumer reporting agency will require you to
provide appropriate proof of your identity, which may include your Social Security number. If
you ask for an extended alert, you will have to provide an identity theft report. An identity theft
report includes a copy of a report you have filed with a federal, state, or local law enforcement
agency, and additional information a consumer reporting agency may require you to submit. For
more detailed information about the identify theft report, visit
www.consumerfinance.gov/learnmore.
2.
You have the right to free copies of the information in your file (your “file disclosure”).
An initial fraud alert entitles you to a copy of all the information in your file at each of the three
nationwide agencies, and an extended alert entitles you to two free file disclosures in a 12month period following the placing of the alert. These additional disclosures may help you
detect signs of fraud, for example, whether fraudulent accounts have been opened in your
name or whether someone has reported a change in your address. Once a year, you also have
the right to a free copy of the information in your file at any consumer reporting agency, if you
believe it has inaccurate information due to fraud, such as identity theft. You also have the
ability to obtain additional free file disclosures under other provisions of the FCRA. See
www.consumerfinance.gov/learnmore.
3.
You have the right to obtain documents relating to fraudulent transactions
made or accounts opened using your personal information. A creditor or other
business must give you copies of applications and other business records relating to
transactions and accounts that resulted from the theft of your identity, if you ask for them in
writing. A business may ask you for proof of your identity, a police report, and an affidavit
before giving you the documents. It may also specify an address for you to send your request.
Under certain circumstances, a business can refuse to provide you with these documents. See
www.consumerfinance.gov/learnmore.
4.
You have the right to obtain information from a debt collector. If you ask, a debt
collector must provide you with certain information about the debt you believe was incurred
in your name by an identity thief – like the name of the creditor and the amount of the debt.
5.
If you believe information in your file results from identity theft, you have the right to
ask that a consumer reporting agency block that information from your file. An identity thief
may run up bills in your name and not pay them. Information about the unpaid bills may appear
on your consumer report. Should you decide to ask a consumer reporting agency to block the
reporting of this information, you must identify the information to block, and provide the
consumer reporting agency with proof of your identity and a copy of your identity theft report.
The consumer reporting agency can refuse or cancel your request for a block if, for example, you
don’t provide the necessary documentation, or where the block results from an error or a
material misrepresentation of fact made by you. If the agency declines or rescinds the block, it
must notify you. Once a debt resulting from identity theft has been blocked, a person or
business with notice of the block may not sell, transfer, or place the debt for collection.
6.
You also may prevent businesses from reporting information about you to
consumer reporting agencies if you believe the information is the result of identity theft.
To do so, you must send your request to the address specified by the business that reports
the information to the consumer reporting agency. The business will expect you to identify
what information you do not want reported and to provide an identity theft report.
To learn more about identity theft and how to deal with its consequences, visit
www.consumerfinance.gov/learnmore, or write to the Consumer Financial Protection
Bureau. You may have additional rights under state law. For more information, contact your
local consumer protection agency or your state Attorney General.
In addition to the new rights and procedures to help consumers deal with the effects
of identity theft, the FCRA has many other important consumer protections. They are
described in more detail at www.consumerfinance.gov/learnmore.
(Updated: November 2012)
