Applicants are not required to give any information prohibited by law. It is our policy
to comply with all applicable state and federal laws prohibiting discrimination in employment
based on race, age, color, sex, religion, national origin, or other protected classification.

Job/Location

BASIC INFORMATION

Name*

First*

Last*

Email*

Date of Birth*

Address*

Street Address*

City*

State*

Zip*

Phone Number*

Social Security #*

When can you start?*

Do you have the proper identification to verify U.S. citizenship or the right to work in the United States on an unrstricted basis?*

YesNo

Are you over 18 years of age?*

YesNo

Are there any hours, shifts, or days you cannot or will not work?*

Have you ever served in the U.S. military?*

Yes
No


Have you ever been convicted of a crime resulting in a misdemanor and/or felony?

Yes
No


Do you have a physical or medical condition which would limit your capacity for the job?

Yes
No


EDUCATION
BUSINESS OR TECHNICAL SCHOOL

Name and location of school

From

To

Major

Diploma or degree received

HIGH SCHOOL

Name and location of school

From

To

Major

Diploma or degree received

COLLEGE/UNIVERSITY

Name and location of school

From

To

Major

Diploma or degree received

GRADUATE SCHOOL

Name and location of school

From

To

Major

Diploma or degree received

OTHER TRAINING / EDUCATION

Name and location of school

From

To

Major

Diploma or degree received

OFFICIAL CERTIFIED COPIES OF TRANSCRIPTS, CERTIFICATES, AND ETC. MAY BE REQUIRED.

Do you hold any professional licenses or certificates?

In addition to your work history, list any other experience, skills, or qualifications.

DRIVERS LICENSE

State*

Number*

Class*

Do you currently have any points against your driver's license?

Yes
No


Have you ever had a substantiated report of child abuse or neglect?

Yes
No


WORK HISTORY

Start with your present or most recent position and work backwards.

Job #1

Dates of Employment

From

To

Exact title of position

Hours worked per week

Starting Salary

Ending Salary

Company Name

Company Phone Number

Name & title of immediate supervisor

Supervisor's Phone Number

May we contact?

YesNo

Reason for leaving

Description of work

Job #2

Dates of Employment

From

To

Exact title of position

Hours worked per week

Starting Salary

Ending Salary

Company Name

Company Phone Number

Name & title of immediate supervisor

Supervisor's Phone Number

May we contact?

YesNo

Reason for leaving

Description of work

Job #3

Dates of Employment

From

To

Exact title of position

Hours worked per week

Starting Salary

Ending Salary

Company Name

Company Phone Number

Name & title of immediate supervisor

Supervisor's Phone Number

May we contact?

YesNo

Reason for leaving

Description of work

REFERENCES

Please provide a list of three (3) persons who are NOT RELATED TO YOU AND WHO HAVE DEFINITE KNOWLEDGE OF YOUR QUALIFICATIONS.

Reference #1

Name*

How Known*

How Long*

Phone*

Email*

Reference #2

Name*

How Known*

How Long*

Phone*

Email*

Reference #3

Name*

How Known*

How Long*

Phone*

Email*

EEO INFORMATION

Name*

Date of Birth*

Sex

MaleFemale

Ethnic Group*

Marital Status*

List any handicaps, physical disabilities, or chronic diseases:

Have you ever been treated for mental illness?

Yes
No


A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT

The federal 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 CRA’s are credit bureaus that gather and sell information about you — such as if you pay your bills on time or have filed bankruptcy — to creditors, employers, landlords, and other businesses. You can find the complete text of the FCRA, 15 U.S.C. 1681 — 1681u. at the Federal Trade Commission’s web site (http://www.ftc.gov). The FCRA gives you specific rights, as outlined below. You may have additional rights under state law. You may contact a state or local consumer protection agency or a state attorney general to learn those rights.

  • 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 tell you, and give you the name, address, and phone number of the CRA that provided the consumer report.
  • You can find out what is in your file. At your request, a CRA must give you the information in your file, and a list of everyone who has requested it recently. There is no charge for the report if a person has taken action against you because of information supplied by the CRA, if you request the report within 60 days of receiving notice of the action. You also are entitled to one free report every twelve months upon request 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 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 investigate the items (usually within 30 days) by presenting to its information source all relevant evidence you submit, unless your dispute is frivolous, The source must review your evidence and report its findings to the CRA. (The source also must advise national CRA’s — to which it has provided the data — of any error.) The CRA must give you a written report of the investigation and a copy of your report if the investigation results in change. If the CRA’s investigation does not resolve the dispute, you may add a brief statement to your file, if an item is deleted or a dispute statement is filed, you may ask that anyone who has recently received your report be notified of the change.
  • Inaccurate information must be corrected or deleted. A CRA must remove or correct inaccurate or unverified information from its files, usually within 30 days after you dispute it. However, the CRA is not required to remove accurate data from your file unless it is outdated (as described below) or cannot be verified. If your dispute results in any change to your report, the CRA cannot reinsert into your file a disputed item unless the information source verifies its accuracy and completeness. In addition, the CRA must give you a written notice telling you it has reinserted the item. The notice must include the name, address and phone number of the information source.
  • You can dispute inaccurate items with the source of the information. If you tell anyone — such as a creditor who reports to a CR.A — 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, it may not continue to report the information if it is in fact, the 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 people with a need recognized by the FCR.A — usually to consider an application with a creditor, insurer, employer, landlord, or other business.
  • Your consent is required for reports that are provided to employers, or reports that contain medical information. A CPA may not give out information about you to your employer, or prospective employer, without your written consent. A CRA may not report medical information about you to creditors, insurers, or employers without your permission.
  • You may choose to exclude your name from CRA 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 phone number for you to call if you want your name and address removed from future lists. If you call, you must be kept off the list for two years. If you request, complete, and return CPA form provided for this purpose, you must be taken off the lists indefinitely.
  • You may seek damages from violators. If a CPA, a user or (in some cases) a provider of CPA data violates the FCRA, you may sue them in state or federal court.
FOR QUESTIONS OR CONCERNS REGARDING: PLEASE CONTACT:
CRAs, creditors and others not listed below Federal Trade Commission
Consumer Response Center — FCRA
Washington, DC 20580 202-326-3761
FREE
National banks, federal branches/agencies of foreign banks (word “National” or initials “N.A.” appear in or after bank’s name Office of the Comptroller of the Currency Compliance Management, Mail Stop 6-6 Washington, DC 20219
800-613-6743 FREE
Federal Reserve System member banks (except national banks, and federal branches/agencies of foreign banks) Federal Reserve Board
Division of Consumer & Community Affairs
Washington, DC 20551
202-452-3693 FREE
Savings associations and federally chartered savings banks (word “Federal” or initials “F,S.B.” appear in federal institution’s name) Office of Thrift Supervision
Consumer Programs
Washington, DC 20552
800-842-6929 FREE
Federal Credit Unions (words “Federal Credit
Union” appear in institution’s name)
National Credit Union Administration
1775 Duke Street Alexandra, VA 22314
J303-5 18-6360
State-chartered banks that are not members of the Federal Reserve System Federal Deposit Insurance Corporation Division of Compliance and Consumer Affairs
Washington, DC 20429
800-934-FDTC FREE
Air, surface, or rail common carriers regulated
by former Civil Aeronautics Board of Interstate Commerce Commission
Department of Transportation
Office of Financial Management
Washington, DC 20590 202-366-1306 FREE
Activities subject to the Packers of Stockyards Act. 1921 Department of Agriculture Office of Deputy Administrator— G1PSA
Washington, DC 20250
202-720-7051 FREE

I certify that the facts set forth in this Application for Employment are true and complete to
the best of my knowledge. I understand that if I am employed, false statements may result in
dismissal. I authorize the CRSE, Inc. Home to make an investigation of any of the facts set
forth in this application.

I understand that employment at the CRSE, Inc. Home is "at will," which means that either
I or the CRSE, Inc. Home can terminate the employment relationship at any time, with or without
prior notice, and for any reason not prohibited by statute, All employment is continued on that
basis. I understand that no supervisor, manager or executive of the agency, other than the Board
of Directors, has any authority to alter the foregoing.

Signature (type your name)*