Please fill out the application in its entirety FIRST MIDDLE LAST AN EQUAL OPPORTUNITY EMPLOYER DATE SOCIAL SECURITY NUMBER 20 PRESENT STREET CITY STATE ZIP PERSONAL PERMANENT TELEPHONE NUMBER HOME STREET WORK EMAIL CITY ARE YOU ELIGIBLE TO WORK IN THE U.S.? IN CASE OF EMERGENCY TIFY: RELATIONSHIP TELEPHONE NUMBER STATE ZIP IS YOUR SPOUSE OR ANY OTHER FAMILY MEMBER EMPLOYED BY ATHER COMPANY THAT IS IN DIRECT COMPETITION WITH OUR COMPANY IF, GIVE RELATIONSHIP AND COMPANY IF RELATED TO ANYONE IN OUR COMPANY LIST, DEPARTMENT AND RELATIONSHIP ARE YOU AGE 18 OR OVER? APPLYING FOR DATE AVAILABLE FOR EMPLOYMENT EARNINGS EXPECTED WHO REFERRED YOU TO OUR COMPANY? APPLIED VOLUNTARILY NEWSPAPER AD COMPANY EMPLOYEE OTHER (SPECIFY) ARE YOU EMPLOYED W? IF SO, MAY WE INQUIRE OF YOUR PRESENT EMPLOYER? HAVE YOU EVER APPLIED TO OR BEEN EMPLOYED BY OUR COMPANY OR ITS SUBSIDIARIES BEFORE? IF, STATE WHERE AND WHEN GENERAL INFORMATION IF NECESSARY, WOULD YOU BE WILLING TO: IF NECESSARY, WOULD YOU BE WILLING TO WORK TRAVEL RELOCATE OVERTIME SATURDAY SUNDAY SHIFT WORK CALL OUTS TRAVEL TIME FROM YOUR HOME TO OUR STORE (OFFICE) DO YOU HAVE RELIABLE TRANSPORTATION? HAVE YOU EVER BEEN CONVICTED OF A FELONY OR MISDEMEAR (OTHER THAN A TRAFFIC VIOLATION) IF, EXPLAIN BRIEFLY PLEASE LIST THREE PERSONS MOST FAMILIAR WITH YOUR ABILITIES AND/OR WHO HAVE KWN YOU PERSONALLY FOR FIVE YEAR OR MORE (DO T USE FAMILY MEMBERS). MAILING OCCUPATION TELEPHONE LIST YOUR HOBBIES OR INTERESTS. SPECIFY SKILLS ACQUIRED AS A RESULT OF THESE ACTIVITIES
HAVE YOU EVER BEEN A MEMBER OF THE U.S. MILITARY FORCES? SPECIAL TRAINING YOU RECEIVED MILITARY IF APPLICABLE, PLEASE COMPLETE THE FOLLOWING BRANCH OF THE SERVICE ARE YOU A MEMBER OF THE U.S. MILITARY RESERVES? DATE ENTERED ACTIVE? DATE DISCHARGED RANK AT DISCHARGE IF AN ACTIVE MEMBER, SHOW ORGANIZATION, LOCATION, GRADE AND COMMITMENT PERIOD. TYPE OF SCHOOL AND OF SCHOOL COURSES IN WHICH YOU MAJORED CIRCLE LAST GRADE ATTENDED DID YOU GRADUATE DEGREE LAST YEAR ATTENDED EDUCATION HIGH SCHOOL TRADE SCHOOL COLLEGE GRADUATE SCHOOL 10 11 12 1 2 3 4 1 2 3 4 5 6 LIST ORGANIZATIONS IN WHICH YOU ARE W A MEMBER OR HAVE BEEN A MEMBER IN THE PAST 10 YEARS. EXCLUDE MEMBERSHIP IN LABOR, RACIAL, OR RELIGIOUS ORGANIZATIONS. INCLUDE PROFESSIONAL, SCIENTIFIC, CIVIC, HORARY, ETC. SHOW DATES AND OFFICES HELD. 20 20 20 20 LIST ANY SPECIAL SCHOOLS (EXTENSION, BUSINESS, COMPANY SPONSORED, CORRESPONDENCE) OR OTHER TRAINING. SHOW DATES OF ATTENDANCE. HOW MANY UNSCHEDULED DAYS OF WORK HAVE YOU MISSED IN THE LAST 24 MONTHS? HAVE YOU EVER HAD AN ACCIDENT ON THE JOB? IF, PLEASE EXPLAIN
HAVE YOU EVER BEEN TERMINATED FROM EMPLOYMENT OR ASKED TO RESIGN BY AN EMPLOYER? IF, PLEASE EXPLAIN WOULD ANY OF YOUR PRIOR EMPLOYERS KW YOU UNDER A DIFFERENT? IF, GIVE AND COMPANY LIST YOUR EMPLOYMENT, UNEMPLOYMENT AND SCHOOLING, ACCOUNTING FOR ALL YOUR ACTIVITIES FOR THE LAST 10 YEARS, START WITH YOUR CURRENT AND LIST THEM IN REVERSE CHROLOGICAL ORDER. EMPLOYMENT FROM TO YR. YR. PRESENT NEXT TO LAST AND OF EMPLOYER IMMEDIATE SUPERVISOR S IMMEDIATE SUPERVISOR S IMMEDIATE SUPERVISOR S IMMEDIATE SUPERVISOR S IMMEDIATE SUPERVISOR S IMMEDIATE SUPERVISOR S IMMEDIATE SUPERVISOR S EMPLOYMENT DATA RATE OF PAY
IF YOU ARE APPLYING FOR A CLERICAL, PLEASE COMPLETE THE FOLLOWING SECTION: OFFICE SKILLS HAVE YOU HAD EXPERIENCE IN: SWITCHBOARD PERSONAL COMPUTER PLEASE DESCRIBE ANY OFFICE SKILLS OTHER THAN TED ABOVE, INCLUDE ANY COMPUTER SOFTWARE WITH WHICH YOU ARE PROFICIENT. TYPE WPM COPIER/SCANNER OTHER BUSINESS MACHINES IF YOU ARE APPLYING FOR A AS A DRIVER OR SERVICE TECHNICIAN, OR A IN THE WAREHOUSE, PLEASE COMPLETE THE FOLLOWING SECTION: OTHER INFORMATION LIST SKILLS, TRADES AND PROFESSIONAL CERTIFICATES IN WHICH YOU HAVE RECOGNIZED PROFICIENCY OR LICENSE. PLEASE DESCRIBED AND INDICATE LEVEL OF PROFICIENCY, WHERE APPLICABLE, AMOUNT OF EXPERIENCE AND THE LAST YEAR YOU WERE ACTIVE IN THIS WORK. LIST PRIOR CATERPILLAR EXPERIENCE. DO YOU HAVE A CURRENT DRIVER S LICENSE? IF UNDER 25 GIVE DATE OF BIRTH HAS YOUR LICENSE EVER BEEN DENIED, SUSPENDED OR REVOKED? NUMBER/STATE NUMBER OF DRIVING ACCIDENTS WITH PERSONALLY OWNED OR COMPANY VEHICLES IN THE LAST 5 YEARS EXPIRES IF, EXPLAIN BRIEFLY TYPE A (COMMERCIAL) B (CHAUFFEUR) NUMBER OF TRAFFIC CITATIONS IN THE LAST 3 YEARS LIST TYPES OF VEHICLES DRIVING EXPERIENCE C (OPERATOR) CDL ARE YOU WILLING TO TAKE A POST-OFFER DRUG SCREEN AND PHYSICAL EXAMINATION? AS A CONDITION OF CONTINUED EMPLOYMENT, SHOULD YOU BE HIRED, ARE YOU WILLING TO UNDERGO A DRUG SCREEN AS DIRECTED BY COMPANY POLICY? APPLICANT STATEMENT I CERTIFY that all of the information contained in this application is true, complete and correct to the best of my knowledge. I UNDERSTAND that any omission, misrepresentation of falsification of this information is cause for non- employment or immediate dismissal from the Company should I be hired. I HEREBY AUTHORIZE investigation of all information and statements contained in this application including, but not limited to, verification of education, military and employment records, and motor vehicle reports, I ALSO AU- THORIZE all necessary credit and consumer investigation reports. Upon my written request, the complete nature and scope of any such investigation report will be disclosed. I HEREBY RELEASE my former employers and other personal and credit reference sources from all liability or damage resulting from having furnished information regarding my work record, personal character or credit history. I ALSO RELEASE Darr Equipment Co. (including its divisions, subsidiaries and affiliates), their employees and agents from all liability or damages should my employment be terminated or I not be hired because of information obtained through such background investigation. I UNDERSTAND that proof of identity and employment authority will be required should I be hired. If accepted for employment, I HEREBY AGREE to abide by all Company policies and procedures now or hereinafter in effect. I UNDERSTAND that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at the option of myself or the Company. DO T WRITE BELOW THIS LINE INTERVIEWER S REMARKS SIGNED DATE OF EMPLOYMENT SALARY $ DATE JOB OR TITLE DEPARTMENT LOCATION APPROVED
DISCLOSURE TO EMPLOYMENT APPLICANT REGARDING PROCUREMENT OF AN INVESTIGATIVE CONSUMER REPORT APPLICANTS COMPLETE THE FOLLOWING: In connection with my application for employment, please be advised that Darr Equipment Co. may conduct a reference check. This reference check, also known as an investigative consumer report, will include information as to my character, work habits, performance, and experience, along with reasons for termination of past employment. I understand that as directed by company policy and consistent with the job described, you may be requesting information from public and private sources about my workers compensation injuries, driving record, court record, education, credentials, credit and references. I hereby authorize, without reservation, any law enforcement agency, institution, information service bureau, school, employer, reference or insurance company contacted by Darr Equipment Co. or its agent, to furnish the information described in the above paragraph. Please be advised that you have the right to request in writing, within a reasonable time, that we make a complete and accurate disclosure of the nature and scope of the information requested. Such disclosure will be made to you within five days of the date on which we receive the request from you or within five days of the time the report was first requested, whichever is later. The Fair Credit Reporting Act gives you specific rights dealing with consumer reporting agencies. You will be given a summary of these rights together with this document. Applicant s Name: (Print Full Name No Abbreviations) Address: (Street) (City) (State) (Zip Code) Social Security Number: Date of Birth: State/Driver s License Number: (State) (License Number) Signature:
Para informacion en espanol, visite www.ftc.gov/credit o escribe a la FTC Consumer Response Center, Room 130-A 600 Pennsylvania Ave. N.W., Washington, D.C 20580. A Summary of your 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 the FCRA. For more information, including information about additional rights, go to www.ftc.gov/credit or write to: Consumer Response Center, Room 103-A, Federal Trade Commission, 600 Pennsylvania Ave. N.W., Washington, D.C. 20580. You must be told in 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: o a person has taken adverse action against you because of information in your credit report; o you are the victim of identity theft and place a fraud alert in your file; o your file contains inaccurate information as a result of fraud; o you are on public assistance; o you are employed but expect to apply for employment within 60 days. In addition, by September 2005 all consumers will be entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.ftc.gov/credit for additional information. You have the right to ask for a credit score. Credit scores are numerical summaries of your creditworthiness 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.ftc.gov/credit for an explanation for 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 to 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.ftc.gov/credit. 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 from 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). 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.ftc.gov/credit. 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. Federal enforcers are:
EQUAL EMPLOYMENT OPPORTUNITY (EEO) CONFIDENTIAL DATA FORM Name: Date: Last First Position or Job Applied For: Location: Who Referred You Applied Voluntarily Company Employee To Our Company? Newspaper Ad Other (Specify) GENERAL DATA: (Please check all that apply) Male Female Age 40 or older Disabled Veteran (other than Vietnam-era) Vietnam-era Veteran (served on active duty between August 5, 1964 and May 7, 1975) Disabled Veteran (Vietnam-era only) Disabled Veteran (other than Vietnam-era) RACE OR ETHNIC DATA: (Please check only one box) HISPANIC OR LATI (H): All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race. WHITE (W): (Not of Hispanic or Latino origin)-all persons having origins in any of the original peoples of Europe, North Africa, or the Middle East BLACK OR AFRICAN AMERICAN (B): (Not of Hispanic or Latino origin)-all persons having origins in any of the Black racial groups of Africa. NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER (P): (not of Hispanic or Latino origin)-all persons having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands. ASIAN (A): (Not of Hispanic or Latino origin)-all persons having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent. AMERICAN INDIAN OR ALASKAN NATIVE (N): (Not of Hispanic or Latino origin)-all persons having origins in the original peoples of North America and who maintain cultural identification through tribal affiliation or community attachment. TWO OR MORE RACES (T): (Not of Hispanic or Latino origin)-all persons who identify with more than one of the above six races. SIGNATURE OFFICE INSTRUCTIONS: The EEO Data Form is to be completed by the applicant at the time the application form is completed. This form, which is used solely for the recording of EEO data, will be completed by applicants on a voluntary basis. The EEO Data Form is not part of the formal application form and must be maintained separately from the application and/or personnel file. At the end of each month, all EEO Data Forms should be submitted to the Human Resources Department.
EQUAL EMPLOYMENT OPPORTUNITY (Vets-100A) CONFIDENTIAL DATA FORM Name: (Please Print) Branch: Please check the appropriate box for the following veteran categories. Disabled Veteran Other Protected Veteran Armed Forces Service Medal Veteran Recently Separated Veterans T a Veteran Definitions: Disabled Veterans: A Veteran of the U.S. Military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; OR, a person who was discharged or released from active duty because of a service-connected disability. Other Protected Veterans: Veterans who served on active duty in the U.S. Military during a war or in a campaign or expedition for which a campaign badge is awarded. Armed Forces Service Medal Veterans: Veterans who, while serving on active duty in the Armed Forces, participated in a United States military for which an Armed Forces service medal was awarded pursuant to Executive Order 12985. Recently Separated Veterans: Veterans within 36 months from discharge or release from active duty. (Signature) (Date)
INVITATION TO EMPLOYEES AND/OR APPLICANTS Darr Equipment Co. is subject to Section 503 of the Rehabilitation Act of 1973 and (38 USC 2012) the Veteran s Readjustment Assistance Act of 1974, which requires affirmative action to employ and advance in employment qualified individuals with disabilities, qualified disabled veterans, and veterans of the Vietnam era. If you are an individual with a disability, a disabled veteran, or a veteran of the Vietnam era and would like to be consider under the Affirmative Action program, please tell us. Submission of this information is voluntary and refusal to provide it will not subject you to discharge or disciplinary treatment. Information shall be kept confidential, except that (1) supervisors and managers may be informed regarding restrictions on the work or duties of the individual with disabilities and disabled veterans, and regarding necessary accommodations, (2) first aid and safety personnel may be informed, when and to the extent appropriate, if the condition might require emergency treatment, and (3) government officials investigating compliance with the Acts shall be informed. If you are an individual with a disability, we would like to include you under the Affirmative Action program. It would assist us if you tell us about (1) any special methods, skills, and procedures which qualify you for the positions that you might not otherwise be able to do because of your disability, or the skills and procedures you use or intended to use to perform the job notwithstanding the disability and (2) the accommodations we could make which would enable you to perform the job properly and safely, including special equipment, changes in the physical layout of the job, elimination of certain duties relating to the job or other accommodations. For further information and reporting forms, please contact the Human Resources Department.
SELF-IDENTIFICATION REPORT FORM (Individuals with disabilities and Vietnam/special disabled veterans) SECTION 503 1. The Rehabilitation Act of 1973 provides that all applicants and employees be offered the opportunity to identify themselves as disabled. A. Do you consider yourself disabled? Yes No B. If yes, what is the nature of your disability? C. Is there any accommodation we may make to assist you? Yes No D. If yes, please explain the accommodation(s). 38 USC 2012 2. It is the policy of Darr Equipment Co. to take affirmative action for disabled veterans and veterans of the Vietnam era. a. If you were a veteran, was your duty performed any time after August 5, 1964, and before May 7, 1975? Yes No b. Are you entitled to disability compensation under the laws administered by the U.S. Veterans Administration for a disability rated at 30 percent or more? Yes No c. Were you discharged or released from active duty in the military service of the U.S. because of a disability incurred or aggravated in the line of duty? Yes No The Affirmative Action program for individuals with disabilities and Vietnam/Era disabled veterans may be reviews by any employee for applicant in the Human Resources Department between the hours of 8:00 a.m. 5:00 p.m.