DISCLOSURE OF BACKGROUND CHECK TO BE CONDUCTED ON YOU

In connection with your application and/or employment with AFIMAC (“Employer”) this notice is provided to inform you that a “consumer report” and/or “investigative consumer report”, as defined by the Fair Credit Reporting Act, may be obtained from a consumer reporting agency for employment purposes. These types of reports may include information as to your character, general reputation, personal characteristics and mode of living, whichever are applicable. The report(s) may also contain information about you relating to your criminal history, credit history, driving and/or motor vehicle records, verification of your education or employment history and other background checks. They may involve interviews with sources such as your neighbors, friends or associates. You have the right, upon written request made within a reasonable amount time after the receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report by contacting Crimcheck.com, Inc. 17295 Foltz Industrial Parkway, Suite B, Strongsville, OH 44149 [1-877-992-4325].

APPLICATION FOR EMPLOYMENT

Please complete all blanks with the required information. Resumes may accompany completed applications.
Additional pages may be attached to complete the required information.

NOTE: fields marked (Required) are mandatory; however, please fill in as many fields as possible.

Personal Information
Are you at least 21 years of age and do you have the legal right to work in the United States?
Yes No
Job Type Applying To
Position Applying For
First Name (Required)
Middle Name
Last Name (Required)
SSN (Required) --
Nickname / Preferred Name
Street Address / Apartment  
City
State / ZIP Code     
Driver's License Number
Driver's License State  
Home Phone (Required) - Area code and phone number
Other Phone - Area code and phone number
Email Address (Required)
How did you hear about us?
Resume - If you have a plain-text resume, paste it into the box below.
*** Please include any professional licenses or certifications! ***
If you are applying for a skilled labor position please make sure to paste a resume below!


Availability
Can you mobilize within 12 to 24 hours?
Yes No
Are you interested in work outside of the US?
Yes No
Are you looking for contract positions?
Yes No
When are you available to start?      
What weekday hours are you available?
What weekend hours are you available?
How many hours are you willing to work in a week?  
Are you willing to work overtime?
Yes No
What is the minimum pay you desire? Hourly rate or annual salary
How much notice will you need if a position is offered to you?
How many miles are you willing to travel to a position?


Education
Enter most recent - Do not enter start and end date if the most recent is high school
Name of School
Type of school  
Street Address
City  
State / ZIP Code   
Start Date (Month / Year)    
End Date (Month / Year)    
Degree  
Major Study Area
Other Studies


Recent Employment
List most recent first
Company Name
Street Address
City
State / ZIP Code   
Company Phone - Area code and phone number
Supervisor Name
Job Title  
Job Duties  
Start Date (Month / Year)      
End Date (Month / Year)    
Start Wage Hourly rate or annual salary
End Wage Hourly rate or annual salary
May we contact this employer for a reference check?
Yes No
Company Name
Street Address
City
State / ZIP Code   
Company Phone - Area code and phone number
Supervisor Name
Job Title  
Job Duties  
Start Date (Month / Year)      
End Date (Month / Year)    
Start Wage Hourly rate or annual salary
End Wage Hourly rate or annual salary
May we contact this employer for a reference check?
Yes No


Military Experience
Military Branch
Rank  
Start Date (Month / Year)      
End Date (Month / Year)    


Criminal Background & Drug Screen
Are you willing to take a drug screening test?   Yes No
 
Citizenship
Are you a citizen of any of the following countries in addition to the USA?
Canada
 
Skills
Agricultural Carpenter  
CDL Driver Chemical Operator
Healthcare CNC Operator
Crane Operator Electrician
Environmental Equipment Operator
Logistics/Food Service General Labor
HVAC Painter
Welder Ironworker
Janitorial Locomotive Engineer
Millwright/Machinist Mason/Concrete
Mechanic Pipe Fitter
Plumber Production Line
Quality Control Security
Stationary Engineer Warehouse
 
 
ACKNOWLEDGMENT AND AUTHORIZATION OF BACKGROUND CHECK

By signing below, I authorize AFIMAC (“Employer”) to obtain “consumer reports” and/or “investigative consumer reports” about me at any time after receipt of this authorization and during the course of my employment, to the extent permitted by law.
Minnesota applicants or employees only: You have the right, upon written request to Crimcheck.com, to receive a complete and accurate disclosure of the nature and scope of any consumer report. Crimcheck.com, Inc. must make this disclosure within five days of receipt of your request or of Employer’s request for the report, whichever is later. Please check the below box if you would like to receive a copy of a consumer report if one is obtained by Employer.

Oklahoma applicants or employees only: Please check the below box if you would like to receive a copy of a consumer report if one is obtained by Employer.

Minnesota and/or Oklahoma request for disclosure:
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 if one is obtained by the Company at no charge whenever you have a right to receive such a copy under California law:
NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW

AFIMAC (“the Company”) intends to obtain information about you from an investigative consumer reporting agency and/or a consumer credit reporting agency for employment purposes. Thus, you can expect to be the subject of "investigative consumer reports" and "consumer credit reports" obtained for employment purposes. Such reports may include information about your character, general reputation, personal characteristics, and mode of living. With respect to any investigative consumer report from an investigative consumer reporting agency ("ICRA"), the Company may investigate the information contained in your employment application and other background information about you, including but not limited to, obtaining a criminal record report, verifying references, work history, your educational achievements, licensure and certifications, obtaining your driving record and other information about you, and interviewing people who are knowledgeable about you. The results of this report may be used as a factor in making employment decisions. The source of any investigative consumer report (as that term is defined under California law) will be Crimcheck.com, Inc. 17295 Foltz Industrial Parkway, Suite B, Strongsville, OH 44149 [1-877-992-4325]. The source of any credit report will be Crimcheck.com, Inc.,17295 Foltz Industrial Parkway, Suite B, Strongsville, OH 44149 [1-877-992-4325]. Information regarding Crimcheck’s, privacy practices (including information about whether any consumer personal information will be sent outside the U.S. or its territories) may be found at www.crimcheck.com.

The Company agrees to provide you with a copy of an investigative consumer report when required to do so under California law.

Under California Civil Code section 1786.22, you are entitled to find out from an ICRA what is in the ICRA’s file on you with proper identification, as follows:

  • In person, by visual inspection of your file during normal business hours and upon reasonable notice. You also may request a copy of the information in person. The ICRA may not charge you more than the actual copying costs for providing you with a copy of your file.
  • A summary of all information contained in the ICRA’s file on you which is required to be provided by the California Civil Code and will be provided to you via telephone, if you have made a written request with proper identification for telephone disclosure and the toll charge, if any, for the telephone call is prepaid by or charged directly to you.
  • By requesting a copy be sent to a specified addressee by certified mail. ICRAs complying with requests for certified mailings shall not be liable for disclosures to third parties caused by mishandling of mail after such mailings leave the ICRAs.
"Proper Identification" includes documents such as a valid driver’s license, social security account number, military identification card, and credit cards. Only if you cannot identify yourself with such information may the ICRA require additional information concerning your employment and personal or family history in order to verify your identity.

The ICRA will provide trained personnel to explain any information furnished to you and will provide a written explanation of any coded information contained in files maintained on you. This written explanation will be provided whenever a file is provided to you for visual inspection.

You may be accompanied by one other person of your choosing, who must furnish reasonable identification. An ICRA may require you to furnish a written statement granting permission to the ICRA to discuss your file in such person’s presence.
Massachusetts and New Jersey applicants or employees only: You have the right to inspect and promptly receive a copy of any investigative consumer report requested by Employer by contacting the consumer reporting agency, Crimcheck.com, Inc., directly.
New York applicants or employees only: You have the right, upon request, to be informed of whether or not a consumer report was requested from a consumer reporting agency by contacting the consumer reporting agency, Crimcheck. If a consumer report is requested, you will again be provided with the name and address of the consumer reporting agency furnishing the report. You may inspect and receive a copy of the report by contacting Crimcheck. By signing, you acknowledge receipt of Article 23-A of the New York Correction Law.
Washington State applicants or employees only: You have the right to receive a complete and accurate disclosure of the nature and scope of any investigative consumer report as well as a written summary of your rights and remedies under Washington law.

I certify that the statements I have made are true and correct and without material omission. I understand that making false statements or omitting pertinent facts is sufficient cause for rejection or dismissal from employment. I authorize obtaining information from any person(s), employers, educational institutions, licensing authorities, and/or law enforcement agencies concerning my background, work habits, skill or conduct on the job, with the exception of past employer(s) I have indicated that are not to be contacted. I hereby release such person or entities from all liability for damages for issuing such information.

I understand that even after an offer of employment is made, employment is conditioned on producing proof of (1) U.S. citizenship or legal authorization to work in the U.S. and (2) birth date and (3) such other information as may be required. I further understand that employment does not begin until actual commencement of work and will require complying with and being bound by safety and other rules and regulations, and may require working overtime shifts, a rotating schedule and/or a schedule other than Monday through Friday.

When I am employed I agree that if at any time I make claims for personal injuries, I will submit myself, upon written request, to examination by a physician or physicians of employer's selection, at employer's expense, as often as may be requested.

I also agree that if I am employed, now or at any time in the future, my employment may be terminated at any time without liability to me for wages or salary except for such wages or salary which I earned prior to the date of my termination. I understand the term of my employment shall be limited to the duration of any assignment 
that I accept.

I am aware that Public Law 91-508, known as the Fair Credit Reporting Act, requires the employer to inform me that a routine inquiry may be made that will provide applicable information concerning my character, my general reputation, my personal characteristics and my credit history. Upon written request, I will provide additional information as to the nature and scope of the inquiry or any report which is produced.

I understand that I am applying for temporary or contract assignments. The completion of this application process shall constitute a conditional offer of employment subject to my availability and the availability of customer assignments calling for the skill and qualifications that I possess, and I agree to consider acceptance of such assignments.

In connection with my application and/or continued employment, (including contract for services) with you, I understand that investigative background inquiries are to be made on myself including consumer investigative criminal convictions. Further, I understand that you will be requesting information from various Federal, State, and other agencies, which maintain records concerning my past activities relating to any criminal experiences.

I acknowledge that I have been counseled that a person or entity may not procure or cause to be prepared an investigative consumer report on any consumer unless it is clearly and accurately disclosed to the consumer, that an investigative consumer report Eincluding all applicable information as to his or her character, general reputation, personal characteristics, mode of living, education history, driving history (including but not limited to accident history, alcohol/drug and any other DOT requirements as permitted by the ADA) employment history and credit history may be made.  If you are denied employment because of the consumer investigation, it is your right under the Fair Credit Reporting Act (Law 91-508) SS 606. to have the name of the agency or agencies from whom information concerning you was obtained.  You are also entitled to receive free copies of the information supplied by those agencies within sixty days upon written request.  You have the right to directly dispute with the consumer reporting agency the accuracy and completeness of any information furnished by that agency.

I authorize without reservation, any party or agency contacted by this employer to furnish the above mentioned information. 

I release BACKGROUND NETWORK, INC. d.b.a. CRIMCHECK.COM and any other person and/or agencies from any suits, liens, judgments, damage and/or liability resulting from this process.

The above information is used solely for inquiries and criminal history checks.

Falsifying any information on this release form will constitute grounds for immediate dismissal or declining any pending job offers.
Please take a moment to review your application.  Indicate that you have read the above statement by entering your initials in the box below.  To complete this application, click on the Submit Application button.
Signature Initials:    


This Company is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications.