central processing corporation application for … · every "consumer reporting agency"...

CENTRAL PROCESSING CORPORATION Application For Employment

Applied at :________________________ Date:_______________________________ (Location)

Name: _______________________________________________ Soc. Sec.# __________________________ (Last) (First) (MI)

Present Address:_______________________________________________________________________________ City: _________________________________ State: _______________ Zip: _____________ Phone: _______________________________ Driver’s License#:____________________________________ Emergency phone:______________________ State Driver’s License issued _____ (example: WI, MN, FL, Etc.) Position of work you are applying for:________________________________________________________________

Full Time Part Time Either Seasonal

When can you start: ______________________ Referral Source:_________________________________________

Wages expected: $__________ per __________ Would you accept another position? Yes___ No ___ Are you over the age of 18 years? Yes No If under 18, do you have a work permit? Yes No Are you legally authorized to work in the U.S.? Yes No Have you previously been employed by this company? Yes No

If yes, from _________to________Position________________________________________________________________ If you have any relatives working for this company, please list them. Name:_____________________ Relationship:__________________________________ Have r misdemeanor regardless of the violation or penalty imposed? you ever been convicted of any felony o

Yes No

The term conviction includes but is not limited to, the payment of fines and pleas of no contest. If "yes", you must provide dates and details below. Do you have any pending arrest charges against you? Yes No If "yes", you must provide the date and details of the type of crime, including the penalty imposed (if applicable) below. Have you ever been a defendant in a civil action for intentional tort? Yes No If "yes", provide the nature of the action and its outcome.

Date(s) and Details:_____________________________________________________________________ _____________________________________________________________________________________ Failure to fully and truthfully respond to this section will result in the denial of employment. The above actions are not absolute bars to employment and will be considered in the hiring process only if there is a substantial relationship to the circumstances of the particular job or if bondability is required for the employee. EDUCATION & TRAINING

School Name and Location Number of Years Completed

Degree and Major Course of Study

Diploma/Degree?

High School Business or Technical College

ADDITIONAL SKILLS/TRAINING/EXPERIENCE

Truck Repair Body Work Inspection Electrical Trailer Repair Lift Truck Loading/Unloading

List specific certifications/training you have received:_____________________________________________________ List additional job-related skills or qualifications: _________________________________________________________

Rev. 03/04/08

EMPLOYMENT RECORD: Please list the names and addresses of your most recent employers.

Employer: Most Recent Position First Employed Work Performed Company Name From:

Job Title FT PT Seasonal

To:

Supervisor’s Name & Phone # Starting Pay

Reason for Leaving Final Pay

Company Name From:


To:



Company Name From:


To:



If you are currently employed, may we contact your employer? Yes No

Disclosures: · I certify the information contained in this application (and accompanying resume or other documents) is true and complete to the

best of my knowledge. I understand that, any misstatements or omissions of information provided during the application or interview process will result in denial of employment and/or dismissal, regardless of when discovered.

· I understand that my employment is contingent upon the verification/completion of my employment record and/or references. The information provided through the completion of the employment record and/or reference verification may result in the denial of employment and/or dismissal.

· The Company may investigate all statements contained in this application (and any resume or any other accompanying documents) as may be necessary. I understand that my prior employers may be contacted for the purpose of investigating my background as required by 49CFR 391.23. I also authorize all personnel, schools, companies, corporations, credit bureaus and law enforcement agencies to supply all pertinent information and release the same from any liability resulting from providing such information.

· I understand that from time to time the company may be asked to submit/release certain information, including but not limited to, my employment or application for employment. I release the company and its agents, from any liability resulting from submitting/releasing such information.

· I acknowledge that the company may request, as a condition of any offer of employment that is made or for continued employment, that I undergo a medical exam or drug testing, and I consent and agree to any such exam, if required now or in the future. I understand that when drug testing is required, a satisfactory result may be a condition of employment.

· I understand that federal law prohibits the employment of unauthorized aliens and requires satisfactory proof of employment authorization and identity. All persons hired must submit satisfactory proof of employment authorization and identity. Please have necessary documents promptly available for inspection as required by law.

· If employed, I agree to abide by the rules and regulations of the company. · I understand that this company is an Equal Opportunity Employer.

· I will inform the Company of any reasonable accommodations I need (under the Americans with Disabilities Act) to complete the application process or to perform any essential elements of the position sought.

· I further acknowledge that this application is not a contract of employment. I realize that if hired, regardless of any oral representations to the contrary, the employment relationship between myself and the Company, and any offer of employment if such is made, is for no fixed period and is terminable-at-will, with or without cause, and with or without prior notice at anytime at the option of the Company or myself.

Rev. 03/04/08

CENTRAL PROCESSING CORPORATION

Please write a paragraph describing the skills, knowledge and expertise you bring to the work force. A short narrative in your own handwriting will be used in evaluating your application for employment. ________________________________________________________________________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Name: _____________________________ (Please Print) Signature:___________________________

Rev. 03/04/08

A P P L I C A N T ’ S D I S C L O S U R E & A U T H O R I Z A T I O N F O R B A C K G R O U N D S C R E E N I N G

APPLICANT INFORMATION (Please Print) Account Number: 101-104746 Applicant Name: (First Middle Last) Current Address: (street address)

Other Name(s) Used: (like Maiden) City: State: Zip:

Gender: * Male Female

Former Address: (1)

Social Security No:* City: State: Zip:

Driver’s License No.: State: Former Address: (2)

Date of Birth: * Place of Birth: (City, State, Country) City: State: Zip:

* This information will be used for purposes of background screening only and will not be used in making any employment decisions.

DISCLOSURE AND AUTHORIZATION NOTICE REGARDING BACKGROUND INVESTIGATION

Employer (“the Company”) may obtain information about you from a consumer reporting agency for employment purposes. Thus, you may be the subject of a “consumer report” and/or an “investigative consumer report” which may include information about your character, general reputation, personal characteristics, and/or mode of living, and which can involve personal interviews with sources such as your neighbors, friends, or associates, including motor vehicle record (or “driving record”) checks, workers compensation records, credit bureau files, employment references, personal references, drug screening, any educational and licensing institution or military branch and to receive any criminal record information pertaining to you which may be in the files of any Federal, State or Local criminal justice agency in Georgia or any other State. These reports may be obtained at any time after receipt of your authorization and, if you are hired, throughout your employment. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your education and/or employment history conducted by InfoMart, 1582 Terrell Mill Road, Marietta, GA 30067, 800-800-3774 or another outside organization. The scope of this notice and authorization is all-encompassing, however, allowing Employer to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and, if you are hired, throughout the course of your employment to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report.

New York and Maine applicants or employees only: You have the right to inspect and receive a copy of any investigative consumer report requested by Employer by contacting the consumer reporting agency identified above directly.

ACKNOWLEDGMENT AND AUTHORIZATION

I acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” at any time after receipt of this authorization and, if I am hired, throughout my employment. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by [the consumer reporting agency] , another outside organization acting on behalf of Employer, and/or Employer itself. I agree that a facsimile (“fax”) or photographic copy of this Authorization shall be as valid as the original.

New York applicants or employees only: By signing below, you also acknowledge receipt of Article 23-A of the New York Correction Law.

Minnesota and Oklahoma applicants or employees only: Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Company. California applicants or employees only: By signing below, you also acknowledge receipt of the NOTICE REGARDING BACKGROUND INVES-TIGATION PURSUANT TO CALIFORNIA LAW. Please check this box if you would like to receive a copy of an investigative consumer report or consumer credit report if one is obtained by the Company at no charge whenever you have a right to receive such a copy under California law. APPLICANT:

Signature: Date: / / Print Name:

Fax to (770) 984-8997

Appendix A to Part 601

Prescribed Summary of Consumer Rights

The prescribed form for this summary is as a separate document, on paper no smaller than 8x11 inches in size, with text no less than 12-point type (8-point for the chart of federal agencies), in bold or capital letters as indicated. The form in this appendix prescribes both the content and the sequence of items in the required summary. A summary may accurately reflect changes in numerical items that change over time (e.g., dollar mounts, or phone numbers and addresses of federal agencies), and remain in compliance.

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 CRAs 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 CRAs -- 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 any change. If the CRA's investigation does not resolve the dispute, you may add a brief statement to your file. The CRA must normally include a summary of your statement in future reports. 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 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, it may not continue to report the information 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 thanseven 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 FCRA -- 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 CRA 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.

Rev. 03/04/08

• 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 lists for two years. If you request, complete, and return the CRA form provided for this purpose, you must be taken off the lists indefinitely.

• You may seek damages from violators. If a CRA, a user or (in some cases) a provider of CRA data, violates the FCRA, you may sue them in state or federal court.

The FCRA gives several different federal agencies authority to enforce the FCRA:

Rev. 03/04/08

CENTRAL PROCESSING CORPORATION

This page is for additional information. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________________________________________________________________________

Rev. 03/04/08

This EmployerParticipates in E-Verify

This employer will provide the Social Security Administration

(SSA) and, if necessary, the Department of Homeland Security

(DHS), with information from each new

employee’s Form I-9 to confirm work

authorization.

IMPORTANT: If the Government cannot

confirm that you are authorized to work,

this employer is required to provide you

written instructions and an opportunity

to contact SSA and/or DHS before taking

adverse action against you, including

terminating your employment.

Employers may not use E-Verify to pre-screen job applicants or

to re-verify current employees and may not limit or influence the

choice of documents presented for use on the Form I-9.

In order to determine whether Form I-9 documentation is valid,

this employer uses E-Verify’s photo screening tool to match

the photograph appearing on some

permanent resident and employment

authorization cards with the official U.S.

Citizenship and Immigration Services’

(USCIS) photograph.

If you believe that your employer has

violated its responsibilities under this

program or has discriminated against

you during the verification process

based upon your national origin or

citizenship status, please call the Office of Special Counsel at

1-800-255-7688 (TDD: 1-800-237-2515).

N O T I C E:

Federal law requires all employers

to verify the identity and employment eligibility

of all persons hired to work in the United States.

For more information on E-Verify, please contact DHS at:

1-888-464-4218

PO Box 218 • Marathon, WI 54448-0218

Tel (715) 848-1365 • toll free (800) 289-2569

Form 1000GG

Rev.11/10

COMPLETING THIS FORM IS VOLUNTARY AND IS NOT A REQUIREMENT FOR EMPLOYMENT

INVITATION TO IDENTIFY FOR AFFIRMATIVE ACTION PURPOSES Various agencies of the United States Government require employers to maintain information on applicants pertaining to factors such as race, sex, and type of position applied for. The information requested on this sheet is for the purpose of our compliance with these record-keeping requirements and to determine recruiting and employment patterns. Central Processing Corporation believes all persons are entitled to equal employment opportunities and does not discriminate against its employees or applicants for employment because of race, color, sex, religion, national origin, physical or mental disability, veteran status, age or marital status.

NAME: DATE:

LAST FIRST MI

CITY/STATE OF RESIDENCE:

POSITION APPLIED FOR: LOCATION:

PLEASE COMPLETE THE FOLLOWING:

1. SEX/RACIAL IDENTIFICATION:

� Male � Female

Check the box that most accurately describes your racial/ethnic identity. You have the option of selecting more than one racial

identification.

� White � Black/African American � Hispanic or Latino (All Races)

� Asian � American Indian or Alaska Native � Hispanic or Latino (White Race Only)

� Native Hawaiian or Other Pacific Islander � Hispanic or Latino (All Other Races)

*Race Identification: you have the option of selecting one or more racial designations.

White – a person having origins in any of the original peoples of Europe, North Africa or the Middle East.

Black or African American – a person having origins in any of the Black racial groups of Africa. Terms such as “Haitian” or

“Negro” can be used in addition to “Black or African American”.

Asian – a person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian subcontinent including, for

example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand or Vietnam.

American Indian or Alaska Native – a person having origins in any of the original peoples of North and South America (including

Central America), and who maintains tribal affiliation or community attachment.

Hispanic or Latino (All Races) – a person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or

origin, regardless of race.

Hispanic or Latino (White Race Only) – a person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish

culture or origin, regardless of race, and of the White Race.

Hispanic or Latino (All Other Races)– a person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish

culture or origin, regardless of race, and of any other race other than White.

Native Hawaiian or Other Pacific Islander – a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or

other Pacific Islands.

2. How were you referred to this job:

� Advertisement � School/College � Employee Referral

� State Job Service � Employment Agency � Temporary Agency

� Government Agency/service � Walk-In � Recruiter

� Veterans service � Other (Please Specify):

The foregoing is accurate to the best of my knowledge.

Signature: Date:

IF YOU HAVE THE RIGHT TO WORK, Don’t let anyone take it away.

If you have a legal right to work in the United States, there are laws to protect you against discrimination in the workplace.

You should know that –

No employer can deny you a job or fire you because of your national origin. Unless mandated by law or government contract, employers cannot require you to be a U.S. Citizen or permanent resident or refuse any legally acceptable documents.

If any of these things have happened to you, you may have a valid charge of discrimination that can be filed with the OSC. Contact the OSC for assistance in your own language.

Call 1-800-255-7688. TDD for the hearing impaired is 1-800-237-2515.

In the Washington, D.C., area, please call 202-616-5594, TDD 202-616-5525

Or write to: U.S. Department of Justice Office of Special Counsel - NYA 950 Pennsylvania Ave., N.W. Washington, DC 20530

U.S. Department of Justice Civil Rights Division

Office of Special Counsel for Immigration-Related Unfair Employment Practices

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

For additional information: 1-866-4US-WAGE (1-866-487-9243) TTY: 1-877-889-5627 WWW.WAGEHOUR.DOL.GOV

U.S. Department of Labor | Employment Standards Administration | Wage and Hour Division WHD Publication 1420 Revised January 2009

EMPLOYEE RIGHTS AND RESPONSIBILITIES UNDER THE FAMILY AND MEDICAL LEAVE ACT

Basic Leave Entitlement FMLA requires covered employers to provide up to 12 weeks of unpaid, job-protected leave to eligible employees for the following reasons: • For incapacity due to pregnancy, prenatal medical care or child birth; • To care for the employee’s child after birth, or placement for adoption

or foster care; • To care for the employee’s spouse, son or daughter, or parent, who has

a serious health condition; or • For a serious health condition that makes the employee unable to

perform the employee’s job.

Military Family Leave Entitlements Eligible employees with a spouse, son, daughter, or parent on active duty or call to active duty status in the National Guard or Reserves in support of a contingency operation may use their 12-week leave entitlement to address certain qualifying exigencies. Qualifying exigencies may include attending certain military events, arranging for alternative childcare, addressing certain financial and legal arrangements, attending certain counseling sessions, and attending post-deployment reintegration briefings. FMLA also includes a special leave entitlement that permits eligible employees to take up to 26 weeks of leave to care for a covered servicemember during a single 12-month period. A covered servicemember is a current member of the Armed Forces, including a member of the National Guard or Reserves, who has a serious injury or illness incurred in the line of duty on active duty that may render the servicemember medically unfit to perform his or her duties for which the servicemember is undergoing medical treatment, recuperation, or therapy; or is in outpatient status; or is on the temporary disability retired list.

Benefits and Protections During FMLA leave, the employer must maintain the employee’s health coverage under any “group health plan” on the same terms as if the employee had continued to work. Upon return from FMLA leave, most employees must be restored to their original or equivalent positions with equivalent pay, benefits, and other employment terms. Use of FMLA leave cannot result in the loss of any employment benefit that accrued prior to the start of an employee’s leave.

Eligibility Requirements Employees are eligible if they have worked for a covered employer for at least one year, for 1,250 hours over the previous 12 months, and if at least 50 employees are employed by the employer within 75 miles.

Definition of Serious Health Condition A serious health condition is an illness, injury, impairment, or physical or mental condition that involves either an overnight stay in a medical care facility, or continuing treatment by a health care provider for a condition that either prevents the employee from performing the functions of the employee’s job, or prevents the qualified family member from participating in school or other daily activities. Subject to certain conditions, the continuing treatment requirement may be met by a period of incapacity of more than 3 consecutive calendar days combined with at least two visits to a health care provider or one visit and a regimen of continuing treatment, or incapacity due to pregnancy, or incapacity due to a chronic condition. Other conditions may meet the definition of continuing treatment.

Use of Leave An employee does not need to use this leave entitlement in one block. Leave can be taken intermittently or on a reduced leave schedule when medically necessary. Employees must make reasonable efforts to schedule leave for planned medical treatment so as not to unduly disrupt the employer’s operations. Leave due to qualifying exigencies may also be taken on an intermittent basis.

Substitution of Paid Leave for Unpaid Leave Employees may choose or employers may require use of accrued paid leave while taking FMLA leave. In order to use paid leave for FMLA leave, employees must comply with the employer’s normal paid leave policies.

Employee Responsibilities Employees must provide 30 days advance notice of the need to take FMLA leave when the need is foreseeable. When 30 days notice is not possible, the employee must provide notice as soon as practicable and generally must comply with an employer’s normal call-in procedures. Employees must provide sufficient information for the employer to determine if the leave may qualify for FMLA protection and the anticipated timing and duration of the leave. Sufficient information may include that the employee is unable to perform job functions, the family member is unable to perform daily activities, the need for hospitalization or continuing treatment by a health care provider, or circumstances supporting the need for military family leave. Employees also must inform the employer if the requested leave is for a reason for which FMLA leave was previously taken or certified. Employees also may be required to provide a certification and periodic recertification supporting the need for leave.

Employer Responsibilities Covered employers must inform employees requesting leave whether they are eligible under FMLA. If they are, the notice must specify any additional information required as well as the employees’ rights and responsibilities. If they are not eligible, the employer must provide a reason for the ineligibility. Covered employers must inform employees if leave will be designated as FMLA-protected and the amount of leave counted against the employee’s leave entitlement. If the employer determines that the leave is not FMLA-protected, the employer must notify the employee.

Unlawful Acts by Employers FMLA makes it unlawful for any employer to: • Interfere with, restrain, or deny the exercise of any right provided under

FMLA; • Discharge or discriminate against any person for opposing any practice

made unlawful by FMLA or for involvement in any proceeding under or relating to FMLA.

Enforcement An employee may file a complaint with the U.S. Department of Labor or may bring a private lawsuit against an employer. FMLA does not affect any Federal or State law prohibiting discrimination, or supersede any State or local law or collective bargaining agreement which provides greater family or medical leave rights.

FMLA section 109 (29 U.S.C. § 2619) requires FMLA covered employers to post the text of this notice. Regulations 29 C.F.R. § 825.300(a) may require additional disclosures.

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