Personal Information
Employment Desired
Education History
Name & Location of School
Level
Did You Graduate?
Subjects Studied & Years Attended
General Information
Former Employers (List the last four employers, starting with the last one first.)
References
AUTHORIZATION
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 and 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 American with
Disabilities Act (ADA) and other relevant federal and state laws.
GUIDELINES – DISCLOSURE AND AUTHORIZATION TO OBTAIN INFORMATION
DISCLOSURE TO CONSUMER
Johnson Specialty Tools, L.L.C.
As part of our hiring background and investigation process, we may obtain, where permitted, one or more reports and
other information about you, including your background, employment history, academic and/or professional credentials,
military service, and
driving history. The information gathered also may involve a criminal history and/or alcohol or drug use
history, if any. An investigative consumer report may include information about your character, general reputation, personal
characteristics, and mode of living that may be obtained by interviews with individuals with whom you are acquainted or who
may have knowledge concerning any such items of information. This also may include contacts of all listed prior employers to
verify your employment history. In addition, if your employment falls under the Federal Department of Transportation
(“DOT”) and the Federal Motor Carrier Safety Administration (“FMCSA”), including 49 CFR § 391.23, the report could include
your driving, safety inspection and performance history from the FMCSA.
Under the provisions of the Fair Credit Reporting Act (“FCRA”), 15 U.S.C §1681 et seq.; FMCSA regulations in the Federal
Code of Regulations, including 49 CFR § 40.329; and certain state laws, before we can seek such reports, where permitted, we
must have your written permission to obtain the information. You have the right, upon written request, to a complete and
accurate disclosure of the nature and scope of the investigation. You also are entitled to a copy of that document entitled,
Rights under the Fair Credit Reporting Act.
Notice to California Applicants. Under California law, the reports ordered about you for employment purposes within the
State of California are defined as “investigative consumer reports.” These reports may contain information on your character,
general reputation, personal characteristics and mode of living. Under California Civil Code § 1786.22, you may view the
report(s) maintained at LS Screen during normal business hours. You also may obtain a copy by submitting proper
identification and paying the cost of duplication by appearing LS Screen in person, by mail, or by telephone. LS Screen is
required to have personnel available to explain the report(s) and to explain any coded information. If you appear in person,
you may be accompanied by a person of your choice, if s/he furnishes proper identification.
AUTHORIZATION AND RELEASE TO OBTAIN INFORMATION
Under the Fair Credit Reporting Act (“FCRA”), 15 U.S.C.§1681 et seq., the regulations applicable to the Federal
Department of Transportation’s Federal Motor Carriers Safety Administration, including 49 CFR § the Americans with
Disabilities Act and all other applicable federal, state, and local laws,
I hereby authorize and permit JOHNSON SPECIALTY
TOOLS, L.L.C. to obtain information, where permitted, pertaining to my employment records,
driving history records, driving
performance and safety history , criminal history, civil records, workers’ compensation (post–offer only), alcohol and drug
testing, verification of my academic and/or professional credentials, and information and/or copies of documents from any
military service records.
I understand that an “investigative consumer report” may result that could include information as to my character,
general reputation, personal characteristics, and mode of living that may be obtained by interviews with individuals with
whom I am acquainted or who may have knowledge concerning any such items of information. I specifically authorize the
release of information by my former employers for the purpose of satisfying driver qualification regulations.
DOT Drivers. I understand that Title 49 of the Federal Code of Regulations, § 391.23, required that my prospective employer
and/or its agent(s) may contact all former employers of a driver within the last three years under the regulation of the
Department of Transportation. Information such as dates of employment, position, accident history, as well as information
pertaining to my drug and alcohol testing history, may be requested from each employer in accordance with Section 391.23
and 49 CFR 40.25
Applicants Legal Name
Current Home Address
