Employment Application

Personal Information

Full Name: *

Date:

Street Address: *

Apartment / Unit:

City:

State:

Zip:

Phone Number:

Email: *

Date Available:

Position Applied For:

Desired Salary:

Are you a Citizen of the United States?: Yes No

If NO, are you authorized to work in the United States?: Yes No

Have you ever worked for this company?: Yes No

If YES, when?:

Have you ever been convicted of a crime?: Yes No

If YES, please explain::

Do you have a valid drivers licence?: Yes No

Education

High School:

Address:

From:

To:

Did you graduate?: Yes No

Diploma:

College:

Address:

From:

To:

Did you graduate?: Yes No

Degree:

Other:

Address:

From:

To:

Did you graduate?: Yes No

Degree:

References

Please list three professional references:

Full name:

Relationship:

Company:

Phone:

Address:

Full name:

Relationship:

Company:

Phone:

Address:

Full name:

Relationship:

Company:

Phone:

Address:

Previous Employment

Company:

Phone:

Address:

Supervisor:

Job Title:

Starting Salary $:

Ending Salary $:

Responsibilities:

From:

To:

Reason For Leaving:

May we contact your previous supervisor for reference?: Yes No

Company:

Phone:

Address:

Supervisor:

Job Title:

Starting Salary $:

Ending Salary $:

Responsibilities:

From:

To:

Reason for Leaving:

May we contact your previous supervisor for reference?: Yes No

Company:

Phone:

Address:

Supervisor:

Job Title:

Starting Salary $:

Ending Salary $:

Responsibilities:

From:

To:

Reason for Leaving:

May we contact your previous supervisor for reference?: Yes No

Military Service

Branch:

From:

To:

Rank at Discharge:

Type of Discharge:

If other than honorable, please explain:

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

I understand that typing my name here counts as my signature.

Signature: *

Date: *

Background Report Release Form

Please Read Carefully

This is to notify you that in connection with your application for employment or temporary assignment we may produce a consumer report. Please be advised that we may also obtain an investigative consumer report including information as to your character, general reputation, personal characteristics and mode of living as part of the process. In the event that information gained from these reports is utilized, either in whole or in part, in making an adverse decision we will provide you with a copy of the consumer report and a description of your summary of rights under the Fair Credit Reporting Act (FCRA) before making an adverse action.

This information may be obtained by contacting your present and previous employers or references supplied by you. The report may cover information including, but not limited to, criminal history reports, and any public records i.e. driving records, education and licensing verifications, personal reference verifications, federal and state blocked party information, medical professional sanctions and Social Security number verification.

Please be advised that you have the right to request a copy of the consumer report in a reasonable amount of time (60 days). We will make a complete and accurate disclosure of the nature and scope of the information requested.

By signing below, I am authorizing PESTOUT INC. to prepare a consumer or investigative consumer report on me as part of the screening process for employment or temporary assignment. During the period in which I retain employment or assignment, I further authorize PESTOUT INC. to obtain additional consumer reports or investigative consumer reports on me to evaluate my reliability for purposes of determining continued access authorization. I also acknowledge that PESTOUT INC. will provide me with a copy of my summary of rights under the fair credit-reporting act (FCRA) if needed.

I additionally authorize all entities having information about me including present and former employers, criminal justice agencies, department of motor vehicles, schools, and credit reporting agencies to release such information to the below indicated party or PESTOUT INC. and to Partnership Screening as the investigative consumer reporting agency, or to any firm retained to conduct such investigations, with all to be treated as the end user of such information without exception.

Name of Requester: PESTOUT INC.

This release and authorization shall remain valid and in effect during the term of your employment. We reserve the right to run additional consumer reports and/or investigative consumer reports on an as needed basis.

Authorized Signature: *

Date: *

Subject / First Name: *

Middle: *

Last: *

Address: *

City: *

State: *

Zip: *

Previous Address: *

City: *

State: *

Zip: *

Subject Email: *

Date of Birth: *

Driver's License Number: *

State Issued: *

For residents of, or for jobs located in California, Maine, Massachusetts, Minnesota, New Jersey. New York, Oklahoma and Washington, you may request a free copy of any background check report by checking the box below.

I request a free copy of the report: I request a free copy of the report

The information that you provide on this form will be used solely for the purpose of identifying or eliminating possible records revealed during the background screening process and will not be used in any way in making an employment or assignment decision

A summary of 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 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 form the lists these offers are based on. You may opt out with the nationwide credit bureaus at 1-888-5-OPTOUT (1-888-567-8688).
The following FCRA right applies with respect to nationwide consumer reporting agencies:

Consumers Have the Right to Obtain a Security Freeze

You have a right to place a “security freeze” on your credit report, which will prohibit a consumer reporting agency from releasing information in your credit report without your express authorization. The security freeze is designed to prevent credit, loans, and services from being approved in your name without your consent. However, you should be aware that using a security freeze to take control over who gets access to the personal and financial information in your credit report may delay, interfere with, or prohibit the timely approval of any subsequent request or application you make regarding a new loan, credit, mortgage, or any other account involving the extension of credit.

As an alternative to a security freeze, you have the right to place an initial or extended fraud alert on your credit file at no cost. An initial fraud alert is a 1-year alert that is placed on a consumer’s credit file. Upon seeing a fraud alert display on a consumer’s credit file, a business is required to take steps to verify the consumer’s identity before extending new credit. If you are a victim of identity theft, you are entitled to an extended fraud alert, which is a fraud alert lasting 7 years.

A security freeze does not apply to a person or entity, or its affiliates, or collection agencies acting on behalf of the person or entity, with which you have an existing account that requests information in your credit report for the purposes of reviewing or collecting the account. Reviewing the account includes activities related to account maintenance, monitoring, credit line increases, and account upgrades and enhancements.

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:

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.

Type of Business and Contact

1a. Banks, savings associations, and credit unions with total assets of over $10 billion and their affiliates

1b. Such affiliates that are not banks, savings associations, or credit unions also should list, in addition to the CFPB:

a. Consumer Financial Protection Bureau, 1700 G Street, N.W. Washington, DC 20552

b. Federal Trade Commission Consumer Response Center 600 Pennsylvania Avenue, N.W. 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

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.

c. Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured state savings associations

d. Federal Credit Unions

a. Office of the Comptroller of the Currency Customer Assistance Group
1301 McKinney Street, Suite 3450, Houston, TX 77010-9050

b. Federal Reserve Consumer Help Center, P.O. Box 1200 Minneapolis, MN 55480

c. FDIC Consumer Response Center, 1100 Walnut Street Box #11, Kansas City, MO 64106

d. National Credit Union Administration, Office of Consumer Financial Protection (OCFP), Division of Consumer Compliance Policy and Outreach, 1775 Duke Street Alexandria, VA 22314

3. Air Carriers

Asst. General Counsel for Aviation Enforcement & Proceedings, Aviation Consumer Protection Division, Department of Transportation, 1200 New Jersey Avenue S.E., Washington, DC 20590

4. Creditors Subject to the Surface Transportation Board

Office of Proceedings, Surface Transportation Board, Department of Transportation, 395 E Street, S.W. Washington, DC 20423

5. Creditors Subject to the Packers and Stockyards Act, 1921

Nearest Packers and Stockyards Administration area supervisor

6. Small Business Investment Companies

Associate Deputy Administrator for Capital Access, United States Small Business Administration, 409 Third Street S.W., Suite 8200, Washington, DC 20416

7. Brokers and Dealers

Securities and Exchange Commission, 100 F Street, N.E., Washington, DC 20549

8. Federal Land Banks, Federal Land Bank Associations, Federal Intermediate Credit Banks, and Production Credit Associations

Farm Credit Administration, 1501 Farm Credit Drive McLean, VA 22102-5090

9. Retailers, Finance Companies, and All Other Creditors Not Listed Above

Federal Trade Commission, Consumer Response Center, 600 Pennsylvania Avenue, N.W. Washington, DC 20580, (877) 382-4357

Employment Application

Personal Information

Education

References

Previous Employment

Military Service

Disclaimer and Signature

Background Report Release Form

Please Read Carefully

A summary of Rights Under the Fair Credit Reporting Act

Consumers Have the Right to Obtain a Security Freeze

Type of Business and Contact

Get Started With PESTOUT Today