Please list two persons not related to you that we may call/email for reference. If you don't have a valid email address for your reference, please use "Your First.Last Name@donotreply.com". Please understand that employers may not be able to contact your reference without a valid email address.

Please list your accident record for the past 5 YEARS. If not applicable, select "NO" from the drop down.

If YES, answer all of the following in the box below:
1. Date of accident
2. Type of accident (example: rear end, head on)
3. Were there fatalities
4. Were there injuries
Include ALL accidents in the last 5 YEARS.
If you answered NO type "N/A" in the box below.

Please list any traffic convictions/forfeitures (other than parking violations) for the past 5 years. If not applicable, select "no".

If YES, answer all of the following in the box below:
1. Date of traffic conviction/forfeiture
2. Location
3. Charge
4. Penalty/Fine
Include ALL traffic convictions/forfeitures in the last 5 YEARS.
If you answered NO, type "N/A" in the box below

"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.

I understand that a consumer credit report or criminal records check may be necessary prior to my employment. If such reports are required, I understand that, in compliance with federal law, the company will provide me with a written notice regarding the use of these reports and will also obtain a separate written authorization from me to consent to these reports. I also understand that a poor credit history or conviction will not automatically result in disqualification from employment"

In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire.

AUTHORIZATION STATEMENT ACKNOWLEDGEMENT

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We are an equal opportunity employer. Qualified minorities, women, veterans and individuals with disabilities are encouraged to apply.