Employment Application An Equal Opportunity Employer
Employment Application An Equal Opportunity Employer Please read carefully
I understand and agree that all products or results of any work which I may do in the course of, or in furtherance of my employment by Eagle Communications, Inc., or any of its subsidiaries, divisions, affiliates, or successors, shall be the sole property of Eagle Communications, Inc. Any patent or copyrighted material, which may be applied for relating to such work-product or result, shall be unconditionally assigned to Eagle Communications, Inc.
I certify that all statements made by me in this application for employment, in the resume I submitted to Eagle Communications, Inc., and during my conversations with members of Eagle Communications, Inc. are true and correct to the best of my knowledge and belief. I understand and agree that any misrepresentation, falsification, or omission of facts made by me on this application, on my resume or during conversations with members of the Eagle Communications, Inc., regardless of when discovered, shall be grounds for disciplinary action, up to and including termination of employment.
I understand and agree that any knowledge whatsoever of a confidential nature, which I may acquire as a result of or in connection with my employment shall remain the sole exclusive property of Eagle Communications, Inc., both during and after termination of my employment.
I hereby authorize Eagle Communications, Inc. to fully investigate my record and work qualifications either before (except present employer) or after my employment (all employers) and to facilitate such investigation, I also hereby authorize any previous employers, educational institutions and credit reporting agencies to provide Eagle Communications, Inc. with any information they request. I hereby release my previous employers, educational institutions, and credit reporting agencies from any liability or claims arising out of the release of such information.
I understand and agree that if employed by Eagle Communications, Inc., its affiliates, subsidiaries, divisions, or successors, such employment is not for any definite period, but may be terminated by either party at any time. I further agree to obey all rules, policies and practices of Eagle Communications, Inc. if accepted as an employee.
I understand that employment is contingent upon the following, if required by the company: A. Receipt by the company of pertinent documents. B. Proof of eligibility to be legally employed in the U.S. C. Acceptable outcomes of drug test, physical, motor vehicle report or background check.
I have read and understand the foregoing. Applicant’s Signature
I understand and agree that my employment is contingent upon my acceptance of the terms of Eagle Communications, Inc.
Date
Personal data – complete in detail even if a resume has been or is being submitted. Last Name
First Name
Middle Initial
Street Address
E-mail Home Phone Number
City
State
Position Applied For
Zip Code
Cell/Business Number
Date Available
Minimum Salary Desired
Are you available to work:
Referral Source
Full-time
Eagle Website Post Website TV Ad Channel Radio Ad Word of Mouth
Part-time Temporary Assignment Summer/Seasonal Assignment
Employment Agency: Job Search Website: Other: Do you have any relative employed by Eagle Communications? If yes, name and relationship:
Are you at least 18 years old?
Have you ever been employed by Eagle Communications or an affiliate company before?
Yes
Yes
No
No
If yes, give date and location.
Do you currently have a valid drivers license? (Possessing and maintaining a valid drivers license may be required of the position.) Yes No In the past three years: Have you been convicted of or pled guilty to any misdemeanors? Yes No any DUIs license revoked/suspended Do you have any charges currently pending?
Yes
No
Are you prevented from lawfully becoming employed in this country because of visa or immigration status? Yes
No
Alien Registration No.
Have you ever been convicted of a felony? If yes, please explain. (A conviction will not be an automatic bar to employment.) Yes
No
If offered employment, a physical examination and substance abuse screening may be required as a result of the position applied for. Would you consent to a physical and substance abuse screening? Yes No
Experience — complete in detail even if a resume has been or is being submitted List all former employers, beginning with the present or most recent and working back to your first employer. Use an additional sheet of paper, if necessary, to complete this listing.
1
From (month/year)
To (month/year)
Name of Employer
Starting job title / final job title
Street Address
Immediate supervisor and title
Summarize the nature of work performed and job responsibilities
Reason for leaving
Compensation Hourly
2
From (month/year)
To (month/year)
State
Starting Salary
$
per
$
Immediate supervisor and title
Summarize the nature of work performed and job responsibilities
Reason for leaving
Compensation
To (month/year)
City
State
Starting Salary
$
per
$
Name of Employer
Immediate supervisor and title
Summarize the nature of work performed and job responsibilities
Reason for leaving
Compensation
City
State
Starting Salary
$
Zip
Ending per
$
Name of Employer
per
Telephone Number
Starting job title / final job title
Street Address
Immediate supervisor and title
Summarize the nature of work performed and job responsibilities
Reason for leaving
Compensation Hourly
per
Telephone Number
Street Address
To (month/year)
Zip
Ending
Starting job title / final job title
From (month/year)
per
Telephone Number
Street Address
From (month/year)
Zip
Ending
Starting job title / final job title
Hourly
4
City
Name of Employer
Hourly
3
Telephone Number
City
State
Starting Salary
$
Zip
Ending per
$
per
U.S. Military Service Have you served as a member of the armed forces of the U.S.? If yes, complete the following.
Yes
Entry date
Last rank
Major duties Specialized training
Discharge date
Branch
No # of people under your command
Education — complete in full even if a resume has been or is being submitted School name
Address
Scholastic Average Major/Minor
Degree/Certificate
High School
Extra-curricular activities College (s)
Extra-curricular activities Graduate school (s)
Thesis/ Doctoral Dissertation Technical school/ business school/ others
Course (s) List academic honors, prizes, scholarships, and fellowships
General Information Are you willing to relocate? Yes
No
Are you willing to travel? Extensive
Limited
Not at all
Professional licenses/certifications
Have you ever entered into any employment or other confidentiality agreement that could limit the scope of your employment at Eagle Communications, Inc.? If yes, please provide details.
Yes
No
Please list any inventions or publications you are responsible for, or any patents you own (if none, write none)
List all foreign languages you can speak and understand
Professional/ business references Name 1 2 3
Address
City
State
Zip
Phone No.
Occupation
Accomplishments — please list specific professional and/or academic achievements that you deem relevant to your application for employment.
Personal statement — please provide any information that will help us gain a complete picture of you as a person and as a potential employee, including a brief outline of your career goals and objectives.
Employment office use Position
Application No.
Division/ Department
Human Resources Approval
Physical Date
Starting Date Special Pay/ Shift Differential
Starting Salary
Motor Vehicle Report Authorization and Disclosure As part of the application process for employment at Eagle Communications, Inc., I understand that they and/or its agents may conduct an investigation of my personal information. The investigation might include, but is not limited to names and dates of previous/current employment and motor vehicle records. I understand that these records may be used for the eligibility of my employment. I authorize without reservation the full release of these records and for National Screening Bureau and/or its agents contacted by National Screening Bureau to obtain information from all available resources. In addition, I release and discharge National Screening Bureau, and all of its agents and associates, any expenses, losses, damages, liabilities, or any other charges or complaints for the investigative process. I also authorize the full release of the information described above, without any reservation, throughout any duration of my employment at the above stated company. I also certify that all information provided is correct on the application and my resume to the best of my knowledge. Any false statements provided will be considered just cause for termination of employment. Upon Request, National Screening Bureau will supply a copy of my report and my rights under the Fair Credit Reporting Act. Requests may be directed to: National Screening Bureau, 515 N Ridge Rd., Se. 202, Wichita, KS 67212 or by contacting us at 1-877-263-4405.
Signature:
Date:
The following must be filled out completely for your application to be considered.
< PLEASE PRINT CLEARLY > Last Name
First Name
Middle Name
Other Names Used
If Married – How Long
Maiden Name
Email
Other Email
Home Address
City
State
Zip
How Long yrs mths
If less then 7 years at present address
City
Previous Address
Phone #
Sex MM
Date of Birth DD YYYY
State
Zip
Social Security #
Drivers License #
Race
State Drivers License was issued in:
M F *NOTE: Date of birth, sex, and race are being requested only for purposes of identification in obtaining accurate retrieval.
National Screening Bureau, LLC. 515 N Ridge Road, Suite 202, Wichita, KS 67212 • 316-263-4400, 877-263-4405 Fx:316-223-1094 www.natsb.com • [email protected]
Authorization and Disclosure for Background Check We value our employees, volunteers, safety of children in our care and the people whom we serve. In order to help safeguard those in our care, Eagle Communications, Inc. has joined National Screening Bureau in conducting criminal background history checks on the volunteers and employees who have unsupervised contact with a child, the elderly or persons with disabilities. Disclosure: Please complete this form of basic information about you, which assures the best possible program and safety for all. All information obtained will be handled in a confidential manner. Information may contain information about your character, general reputation, personal characteristics, mode of living, qualifications and credentials. The nature and scope of the consumer report or investigative consumer report is the procurement of reports such as consumer credit, criminal records, civil records, driving records, employment verification, education verification, professional license verification and others. I understand that, upon written request within a reasonable period of time, I am entitled to additional information concerning the nature and scope of this investigation. I also understand you may make use of the internet including social networking sites. I understand that pursuant to the Fair Credit Reporting Act (FCRA), I have the right to know if adverse action is being considered against me as a result of information contained in this report, that I have the right to a copy of this report prior to any adverse action taken against me and to dispute the accuracy of any information in this report by contacting the consumer reporting agency, NATSB, 920 N Tyler Suite 302, Wichita, KS 67212, toll free (877) 263-4405. I understand that I may have additional rights under State law, which I may determine by contacting my State or local consumer protection agency. Oklahoma, Minnesota and California applicants may obtain a copy of this consumer report by checking this line. This report will be sent to California applicants within three (3) days of the employer receiving the report. California applicants only: For consumer reports which were not obtained by a consumer reporting agency, by checking this line you waive the right to obtain a copy of the report. If unchecked, you will receive this report within 7 days of the employer receiving it. California only: For reports obtained by NATSB, California applicants also may review the file NATSB maintains on you during normal business hours, upon submitting proper I.D. and by paying fees associated with making copies of those files. In the State of California, a new Disclosure and Authorization/Release of Information form is required each time a subsequent Consumer/Report/Investigative Consumer Report is going to be requested. The nature and scope of the consumer report or investigative consumer report is the procurement of reports such as consumer credit, criminal, civil records, driving records, employment verification, education verification, professional license verifications and others.
Authorization / Release of Information: I have carefully read and understand the above Disclosure. I hereby authorize the obtaining of consumer reports and investigative consumer reports at any time after receipt of this authorization. I authorize without reservation, any party or agency contacted by National Screening Bureau or NATSB, acting on behalf of National Screening Bureau, to furnish information about my character, reputation, personal characteristics, credentials, and/or credit and indebtedness. I understand this may involve personal interviews with sources such as schools, employers, supervisors, friends, neighbors, associates, state, federal or local agencies, and public record or law enforcement agencies as well as driving record providers. I further authorize ongoing procurement of these reports at any time during my continued employment or contract for services, unless specifically prohibited by state law. I also agree that a fax or photocopy of this authorization with my signature shall be accepted with the same authority as the original.
< PLEASE PRINT CLEARLY > Last Name
First Name
Middle Name
Other Names Used
If Married – How Long
Maiden Name
Email
Other Email
Home Address
City
State
If less then 7 years at present address
City
State
Zip
Social Security #
Drivers License #
Race
State Drivers License was issued in:
Zip
How Long yrs mths
Previous Address
Phone #
Sex M F
Date of Birth MM DD YYYY
*NOTE: Date of birth, sex, and race are being requested only for purposes of identification in obtaining accurate retrieval
Signature:
Date: National Screening Bureau
Fax 316-223-1094
www.natsb.com Revised 06/11/12
I understand and agree that all products or results of any work which I may do in the course of, or in furtherance of my employment by Eagle Communications, Inc., or any of its subsidiaries, divisions, affiliates, or successors, shall be the sole property of Eagle Communications, Inc. Any patent or copyrighted material, which may be applied for relating to such work-product or result, shall be unconditionally assigned to Eagle Communications, Inc.
I certify that all statements made by me in this application for employment, in the resume I submitted to Eagle Communications, Inc., and during my conversations with members of Eagle Communications, Inc. are true and correct to the best of my knowledge and belief. I understand and agree that any misrepresentation, falsification, or omission of facts made by me on this application, on my resume or during conversations with members of the Eagle Communications, Inc., regardless of when discovered, shall be grounds for disciplinary action, up to and including termination of employment.
I understand and agree that any knowledge whatsoever of a confidential nature, which I may acquire as a result of or in connection with my employment shall remain the sole exclusive property of Eagle Communications, Inc., both during and after termination of my employment.
I hereby authorize Eagle Communications, Inc. to fully investigate my record and work qualifications either before (except present employer) or after my employment (all employers) and to facilitate such investigation, I also hereby authorize any previous employers, educational institutions and credit reporting agencies to provide Eagle Communications, Inc. with any information they request. I hereby release my previous employers, educational institutions, and credit reporting agencies from any liability or claims arising out of the release of such information.
I understand and agree that if employed by Eagle Communications, Inc., its affiliates, subsidiaries, divisions, or successors, such employment is not for any definite period, but may be terminated by either party at any time. I further agree to obey all rules, policies and practices of Eagle Communications, Inc. if accepted as an employee.
I understand that employment is contingent upon the following, if required by the company: A. Receipt by the company of pertinent documents. B. Proof of eligibility to be legally employed in the U.S. C. Acceptable outcomes of drug test, physical, motor vehicle report or background check.
I have read and understand the foregoing. Applicant’s Signature
I understand and agree that my employment is contingent upon my acceptance of the terms of Eagle Communications, Inc.
Date
Personal data – complete in detail even if a resume has been or is being submitted. Last Name
First Name
Middle Initial
Street Address
E-mail Home Phone Number
City
State
Position Applied For
Zip Code
Cell/Business Number
Date Available
Minimum Salary Desired
Are you available to work:
Referral Source
Full-time
Eagle Website Post Website TV Ad Channel Radio Ad Word of Mouth
Part-time Temporary Assignment Summer/Seasonal Assignment
Employment Agency: Job Search Website: Other: Do you have any relative employed by Eagle Communications? If yes, name and relationship:
Are you at least 18 years old?
Have you ever been employed by Eagle Communications or an affiliate company before?
Yes
Yes
No
No
If yes, give date and location.
Do you currently have a valid drivers license? (Possessing and maintaining a valid drivers license may be required of the position.) Yes No In the past three years: Have you been convicted of or pled guilty to any misdemeanors? Yes No any DUIs license revoked/suspended Do you have any charges currently pending?
Yes
No
Are you prevented from lawfully becoming employed in this country because of visa or immigration status? Yes
No
Alien Registration No.
Have you ever been convicted of a felony? If yes, please explain. (A conviction will not be an automatic bar to employment.) Yes
No
If offered employment, a physical examination and substance abuse screening may be required as a result of the position applied for. Would you consent to a physical and substance abuse screening? Yes No
Experience — complete in detail even if a resume has been or is being submitted List all former employers, beginning with the present or most recent and working back to your first employer. Use an additional sheet of paper, if necessary, to complete this listing.
1
From (month/year)
To (month/year)
Name of Employer
Starting job title / final job title
Street Address
Immediate supervisor and title
Summarize the nature of work performed and job responsibilities
Reason for leaving
Compensation Hourly
2
From (month/year)
To (month/year)
State
Starting Salary
$
per
$
Immediate supervisor and title
Summarize the nature of work performed and job responsibilities
Reason for leaving
Compensation
To (month/year)
City
State
Starting Salary
$
per
$
Name of Employer
Immediate supervisor and title
Summarize the nature of work performed and job responsibilities
Reason for leaving
Compensation
City
State
Starting Salary
$
Zip
Ending per
$
Name of Employer
per
Telephone Number
Starting job title / final job title
Street Address
Immediate supervisor and title
Summarize the nature of work performed and job responsibilities
Reason for leaving
Compensation Hourly
per
Telephone Number
Street Address
To (month/year)
Zip
Ending
Starting job title / final job title
From (month/year)
per
Telephone Number
Street Address
From (month/year)
Zip
Ending
Starting job title / final job title
Hourly
4
City
Name of Employer
Hourly
3
Telephone Number
City
State
Starting Salary
$
Zip
Ending per
$
per
U.S. Military Service Have you served as a member of the armed forces of the U.S.? If yes, complete the following.
Yes
Entry date
Last rank
Major duties Specialized training
Discharge date
Branch
No # of people under your command
Education — complete in full even if a resume has been or is being submitted School name
Address
Scholastic Average Major/Minor
Degree/Certificate
High School
Extra-curricular activities College (s)
Extra-curricular activities Graduate school (s)
Thesis/ Doctoral Dissertation Technical school/ business school/ others
Course (s) List academic honors, prizes, scholarships, and fellowships
General Information Are you willing to relocate? Yes
No
Are you willing to travel? Extensive
Limited
Not at all
Professional licenses/certifications
Have you ever entered into any employment or other confidentiality agreement that could limit the scope of your employment at Eagle Communications, Inc.? If yes, please provide details.
Yes
No
Please list any inventions or publications you are responsible for, or any patents you own (if none, write none)
List all foreign languages you can speak and understand
Professional/ business references Name 1 2 3
Address
City
State
Zip
Phone No.
Occupation
Accomplishments — please list specific professional and/or academic achievements that you deem relevant to your application for employment.
Personal statement — please provide any information that will help us gain a complete picture of you as a person and as a potential employee, including a brief outline of your career goals and objectives.
Employment office use Position
Application No.
Division/ Department
Human Resources Approval
Physical Date
Starting Date Special Pay/ Shift Differential
Starting Salary
Motor Vehicle Report Authorization and Disclosure As part of the application process for employment at Eagle Communications, Inc., I understand that they and/or its agents may conduct an investigation of my personal information. The investigation might include, but is not limited to names and dates of previous/current employment and motor vehicle records. I understand that these records may be used for the eligibility of my employment. I authorize without reservation the full release of these records and for National Screening Bureau and/or its agents contacted by National Screening Bureau to obtain information from all available resources. In addition, I release and discharge National Screening Bureau, and all of its agents and associates, any expenses, losses, damages, liabilities, or any other charges or complaints for the investigative process. I also authorize the full release of the information described above, without any reservation, throughout any duration of my employment at the above stated company. I also certify that all information provided is correct on the application and my resume to the best of my knowledge. Any false statements provided will be considered just cause for termination of employment. Upon Request, National Screening Bureau will supply a copy of my report and my rights under the Fair Credit Reporting Act. Requests may be directed to: National Screening Bureau, 515 N Ridge Rd., Se. 202, Wichita, KS 67212 or by contacting us at 1-877-263-4405.
Signature:
Date:
The following must be filled out completely for your application to be considered.
< PLEASE PRINT CLEARLY > Last Name
First Name
Middle Name
Other Names Used
If Married – How Long
Maiden Name
Other Email
Home Address
City
State
Zip
How Long yrs mths
If less then 7 years at present address
City
Previous Address
Phone #
Sex MM
Date of Birth DD YYYY
State
Zip
Social Security #
Drivers License #
Race
State Drivers License was issued in:
M F *NOTE: Date of birth, sex, and race are being requested only for purposes of identification in obtaining accurate retrieval.
National Screening Bureau, LLC. 515 N Ridge Road, Suite 202, Wichita, KS 67212 • 316-263-4400, 877-263-4405 Fx:316-223-1094 www.natsb.com • [email protected]
Authorization and Disclosure for Background Check We value our employees, volunteers, safety of children in our care and the people whom we serve. In order to help safeguard those in our care, Eagle Communications, Inc. has joined National Screening Bureau in conducting criminal background history checks on the volunteers and employees who have unsupervised contact with a child, the elderly or persons with disabilities. Disclosure: Please complete this form of basic information about you, which assures the best possible program and safety for all. All information obtained will be handled in a confidential manner. Information may contain information about your character, general reputation, personal characteristics, mode of living, qualifications and credentials. The nature and scope of the consumer report or investigative consumer report is the procurement of reports such as consumer credit, criminal records, civil records, driving records, employment verification, education verification, professional license verification and others. I understand that, upon written request within a reasonable period of time, I am entitled to additional information concerning the nature and scope of this investigation. I also understand you may make use of the internet including social networking sites. I understand that pursuant to the Fair Credit Reporting Act (FCRA), I have the right to know if adverse action is being considered against me as a result of information contained in this report, that I have the right to a copy of this report prior to any adverse action taken against me and to dispute the accuracy of any information in this report by contacting the consumer reporting agency, NATSB, 920 N Tyler Suite 302, Wichita, KS 67212, toll free (877) 263-4405. I understand that I may have additional rights under State law, which I may determine by contacting my State or local consumer protection agency. Oklahoma, Minnesota and California applicants may obtain a copy of this consumer report by checking this line. This report will be sent to California applicants within three (3) days of the employer receiving the report. California applicants only: For consumer reports which were not obtained by a consumer reporting agency, by checking this line you waive the right to obtain a copy of the report. If unchecked, you will receive this report within 7 days of the employer receiving it. California only: For reports obtained by NATSB, California applicants also may review the file NATSB maintains on you during normal business hours, upon submitting proper I.D. and by paying fees associated with making copies of those files. In the State of California, a new Disclosure and Authorization/Release of Information form is required each time a subsequent Consumer/Report/Investigative Consumer Report is going to be requested. The nature and scope of the consumer report or investigative consumer report is the procurement of reports such as consumer credit, criminal, civil records, driving records, employment verification, education verification, professional license verifications and others.
Authorization / Release of Information: I have carefully read and understand the above Disclosure. I hereby authorize the obtaining of consumer reports and investigative consumer reports at any time after receipt of this authorization. I authorize without reservation, any party or agency contacted by National Screening Bureau or NATSB, acting on behalf of National Screening Bureau, to furnish information about my character, reputation, personal characteristics, credentials, and/or credit and indebtedness. I understand this may involve personal interviews with sources such as schools, employers, supervisors, friends, neighbors, associates, state, federal or local agencies, and public record or law enforcement agencies as well as driving record providers. I further authorize ongoing procurement of these reports at any time during my continued employment or contract for services, unless specifically prohibited by state law. I also agree that a fax or photocopy of this authorization with my signature shall be accepted with the same authority as the original.
< PLEASE PRINT CLEARLY > Last Name
First Name
Middle Name
Other Names Used
If Married – How Long
Maiden Name
Other Email
Home Address
City
State
If less then 7 years at present address
City
State
Zip
Social Security #
Drivers License #
Race
State Drivers License was issued in:
Zip
How Long yrs mths
Previous Address
Phone #
Sex M F
Date of Birth MM DD YYYY
*NOTE: Date of birth, sex, and race are being requested only for purposes of identification in obtaining accurate retrieval
Signature:
Date: National Screening Bureau
Fax 316-223-1094
www.natsb.com Revised 06/11/12
