| Personal Information: |
| First Name: |
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Middle Name |
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| Last Name |
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Home Phone Number: |
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| Present Street Address: |
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Zip: |
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| Date From: |
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Date To: |
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| Email Address: |
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| Position Desired: |
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| Position Desired: |
Full Time
Part Time |
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| Additional Addresses: |
| If you have had any other residences in the last five (5) years, please list them in the box below. If not, please leave the box blank. |
Additional Addresses:
(must be less than 5,000 characters) |
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| Emergency Contact: |
| Name: |
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| Phone Number: |
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| Relationship: |
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| Additional Employment Information: |
| Are you legally eligible to be an employee in the United States ? |
Yes
No |
| Can you provide proof? |
Yes
No |
| Are you 18 years of age or older? |
Yes
No |
| Do you have the proper work permits? |
Yes
No
N/A |
| How soon can you report to work? |
mm/dd/yy
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| Salary Requirements: |
| Rate of pay expected: |
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Per |
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| Were you referred to us by a current employee? |
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| Criminal History: |
| Have you ever been convicted of, or plead no contest to, a criminal offense, specifically involving dishonesty or breach of trust (including and not limited to robbery, embezzlement, forgery, perjury, tax evasion, etc.)? Checking "Yes" does not disqualify you from possible employment. |
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| If so, state dates, place, courts, where offense occurred and judgment given: |
(must be less than 5,000 characters) |
| United Solutions Company and other Employment History: |
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| If so, please explain, |
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| Previous Employment: |
| SHOW PRESENT/PAST EMPLOYMENT FOR THE PAST FIVE YEARS INCLUDING PART TIME EMPLOYMENT: |
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| References: |
| Additional References (if employment experience yields less than three contacts) |
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| Additional Information: |
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Why do you desire to make a change?
(must be less than 8,000 characters)
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| Consistent attendance and punctuality are essential requirements of every job. Will you have the ability to punctually and consistently attend work if you are offered a job? |
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| Have you ever held a position of trust (handling money or confidential material)? |
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| Are you able to perform the essential requirements of the job? |
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If not, are there reasonable accomodations that can be made to allow you to perform the essential functions of the job?
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| Education: |
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| Additional Skills: |
List those skills or abilities that you consider relevant to this job. Also name and briefly describe courses taken in school, present or past positions, other experience that will especially fit you for the position for which you apply:
(must be less than 8,000 characters) |
ACTIVITIES (Only activities you consider relevant to your ability to perform this job should be listed; exclude organizations, the names or character of which indicates the race, creed, color, religion or national origin of its members.) List only those activities, such as civic, athletic, fraternal, etc., that you consider relevant to this job.
(must be less than 8,000 characters) |
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| Drug-Free Workplace : |
| Workers' Compensation Premium Credit Program
Pre-Employment Substance Abuse Screening
United Solutions Company acknowledges the problem of substance abuse (including alcohol) in our society. Furthermore, United Solutions Company recognizes that substance abuse can be a serious threat to our staff, shareholders and vendors. We are addressing this problem by introducing a substance abuse policy to ensure that United Solutions Company will have a drug-free workplace.
All job applicants at United Solutions Company will undergo screening for the presence of illegal drugs or alcohol as a condition for employment.
Applicants will be required to submit to a test at a qualified laboratory, chosen by United Solutions Company. Signing this consent agreement will release United Solutions Company from liability.
Any applicant who refuses to take the test, or who alters, tampers with, or substitutes a urine specimen, or whose test results are positive will be denied employment. You may initiate another inquiry with United Solutions Company after one (1) year.
United Solutions Company will not discriminate against applicants for employment because of past abuse of drugs or alcohol. It is the CURRENT abuse of drugs or alcohol that prevents employees from properly performing their jobs.
I acknowledge and understand that United Solutions Company is a drug-free workplace and has a policy concerning substance abuse.
Please click here for a printable version of:
"Drug-Free Workplace Policy"
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| Release Form for Consumer Reports: |
Investigative Consumer Report Authorization for Employment Purposes
By signing below, you hereby authorize UNITED SOLUTIONS COMPANY or their designee to obtain an investigative consumer report on you. A copy of your summary of rights is provided below and you have the right to request additional disclosures of the nature and scope of the investigations that were conducted.
I hereby authorize without reservation, any party or agency contacted by this employer to furnish the above mentioned information. |
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| A DISCLOSURE AND AUTHORIZATION PURSUANT TO THE FAIR CREDIT REPORTING ACT |
PURSUANT TO THE FEDERAL FAIR CREDIT REPORTING ACT (15 U.S.C.§ 1681,) YOU ARE ON NOTICE THAT UNITED SOLUTIONS COMPANYMAY OBTAIN A CONSUMER REPORT (CREDIT REPORT) IN CONJUCTION WITH YOUR EMPLOYMENT APPLICATION AND/OR DECISIONS CONCERNING YOUR EMPLOYMENT STATUS WITH UNITED SOLUTIONS COMPANY
YOUR SIGNATURE AT THE BOTTOM OF THIS NOTICE IS AUTHORIZATION FOR UNITED SOLUTIONS COMPANY TO OBTAIN AND CONSULT YOUR CONSUMER REPORT FROM A CONSUMER REPORTING AGENCY IN MAKING EMPLOYMENT DETERMINATIONS, INCLUDING BUT NOT LIMITED TO EMPLOYMENT, PROMOTION, REASSIGNMENT AND RETENTION.
YOUR SIGNATURE INDICATES THAT YOU HAVE READ THIS DISCLOSURE AND AUTHORIZATION AND THAT YOU AFFIRM ALL REPRESENTATIONS MADE HEREIN. |
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| A Summary of Your Rights Under the Fair Credit Reporting Act: |
The Fair Credit Reporting Act (FCRA) is designed to promote accuracy, fairness, and privacy of information in the files of every "consumer reporting agency" (CRA). Most CRAs are credit bureaus that gather and sell information about you -- such as where you work and live, if you pay your bills on time, and whether you've been sued, arrested, or filed for bankruptcy -- to creditors, employers, and other businesses. The FCRA gives you specific rights in dealing with CRAs, and requires them to provide you with a summary of these rights as listed below. You can find the complete text of the FCRA, 15 U.S.C. 1681 et seq., at the Federal Trade Commission's web site (http://www.ftc.gov).
- You must be told if information in your file has been used against you. Anyone who uses information from a CRA to take action against you -- such as denying an application for credit, insurance, or employment -- must give you the name, address, and phone number of the CRA that provided the report.
- You can find out what is in your file. A CRA must give you all the information in your file, and a list of everyone who has requested it recently. However, you are not entitled to a "risk score" or a "credit score" that is based on information in your file. There is no charge for the report if your application was denied because of information supplied by the CRA, and if you request the report within 60 days of receiving the denial notice. You are also entitled to one free report a year if you certify that (1) you are unemployed and plan to seek employment within 60 days, (2) you are on welfare, or (3) your report is inaccurate due to fraud. Otherwise, a CRA may charge you a fee of up to eight dollars.
- You can dispute inaccurate information with the CRA. If you tell a CRA that your file contains inaccurate information, the CRA must reinvestigate the items (usually within 30 days) unless your dispute is frivolous. The CRA must pass along to its source all relevant information you provided. The CRA also must supply you with written results of the investigation and a copy of your report, if it has changed. If an item is altered or deleted because you dispute it, the CRA cannot place it back in your file unless the source of the information verifies its accuracy and completeness, and the CRA provides you a written notice that includes the name, address and phone number of the source.
- Inaccurate information must be deleted. A CRA must remove inaccurate information from its files, usually within 30 days after you dispute its accuracy. The largest credit bureaus must notify other national CRAs if items are altered or deleted. However, the CRA is not required to remove data from your file that is accurate unless it is outdated or cannot be verified.
- You can dispute inaccurate items with the source of the information. If you tell anyone -- such as a creditor who reports to a CRA -- that you dispute an item, they may not then report the information to a CRA without including a notice of your dispute. In addition, once you've notified the source of the error in writing, they may not continue to report it if it is in fact an error.
- Outdated information may not be reported. In most cases, a CRA may not report negative information that is more than seven years old; ten years for bankruptcies.
- Access to your file is limited. A CRA may provide information about you only to those who have a need recognized by the FCRA -- usually to consider an application you have submitted to a creditor, insurer, employer, landlord, or other business.
- Your consent is required for reports that are provided to employers or that contain medical information. A CRA may not report to your employer, or prospective employer, about you without your written consent. A CRA may not divulge medical information about you without your permission.
- You can stop a CRA from including you on lists for unsolicited credit and insurance offers. Creditors and insurers may use file information as the basis for sending you unsolicited offers of credit or insurance. Such offers must include a toll-free number for you to call and tell the CRA if you want your name and address excluded from future lists or offers. If you notify the CRA through the toll-free number, it must keep you off the lists for two years. If you request and complete the CRA form provided for this purpose, you can have your name and address removed indefinitely.
- You may seek damages from violators. You may sue a CRA or other party in state or federal court for violations of the FCRA. If you win, the defendant may have to pay damages and reimburse you for attorney fees. If you lose and the court specifically finds you sued in bad faith, you or your attorney may have to pay the defendant's fees.
You may have additional rights under state law. You may wish to contact a state or local consumer protection agency or a state attorney general to learn those rights. If you have questions or believe your file contains errors, call our toll-free number. The FCRA gives several different federal agencies authority to enforce the FCRA:
CRAs, creditors and others not listed below, please contact
Federal Trade Commission
Bureau of Consumer Protection - FCRA
Washington, DC 20580 * 202-326-2222
Federal credit unions (words "Federal Credit Union" appear in institution's name)
National Credit Union Administration
1775 Duke Street
Alexandria, VA 22314 * 703-518-6360
Please click here for a printable version of:
"Summary of Your Rights Under the Fair Credit Reporting Act"
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United Solutions Company
- I hereby agree to being fingerprinted before or during my employment and agree to my fingerprint record being processed by the Federal Bureau of Investigation (FBI).
- I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts called for is cause for dismissal. Further, I understand and agree that my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without any previous notice.
- I fully understand because of the nature of the business conducted by United Solutions Company (USC) that all information, whether written, spoken or otherwise communicated or obtained, and all files and records of any and every description relating to the business of USC or to anyone with whom USC has dealings, constitute privileged matters and are to be treated in a strictly confidential manner. I understand and agree that should I enter the employ of USC, I am not to, and will not at anytime, communicate or reveal any business of USC or any such information or records or files or the matters contained therein to unauthorized personnel within USC, or to anyone outside USC. I also understand that any violation of foregoing shall be sufficient grounds for termination of my employment.
- In the event I am employed by USC, I will comply with all rules and regulations as set forth in USC's policy manual or other communications distributed to all employees.
- I understand that if I am hired, my continued employment may be conditioned upon a health evaluation that may include a physical examination by a doctor selected by USC to which I hereby consent. This health evaluation will also include a chemical analysis to determine whether I am a user or addicted to illegal drugs and/or alcohol, to which I also consent.
- I certify that all statements made by me on this application are true and complete to the best of my knowledge and that I have withheld nothing that would, if disclosed, affect this application unfavorably.
- I understand that I may be asked to voluntarily submit to a polygraph examination as part of an on-going investigation if the employer has sustained an economic loss or injury as a result of actions such as theft or embezzlement.
- I understand that if I am employed, a photograph may be later required.
- I authorize you to communicate with persons listed as references, former employers, and any others with whom you desire to check. I agree to hold such persons harmless with respect to any information they may give about me.
- I understand that USC employs only U.S. citizens and properly authorized aliens. If I become employed, Federal law requires that I furnish to USC proof of my identity and employment authorization and to sign a statement under penalty of perjury verifying my eligibility for employment as a citizen or national of the United States or an otherwise employable alien.
- I hereby acknowledge that I have read the above statement and understand the same.
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| This is to advise you that your application for employment will be processed as quickly as possible. Public Law 91-508 requires that we advise you that a routine inquiry may be made during our initial or subsequent processing which will provide applicable information concerning character and general reputation for honesty and truthfulness. Upon written request, additional information as to the nature and scope of the inquiry, if one is made, will be provided.) |
THIS APPLICATION IS VOID AFTER 60 DAYS, UNLESS RENEWED BY THE APPLICANT. |
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