United Distributors, Inc. GEORGIA CRIMINAL HISTORY CONSENT FORM

Transcription

1 United Distributors, Inc. GEORGIA CRIMINAL HISTORY CONSENT FORM I hereby authorize United Distributors, Inc. to receive any criminal history record information pertaining to me which may be in the files of any state or local criminal justice agency in Georgia. This authorization is valid for the term of my employment should I be hired by the Company. FULL NAME PRINTED ADDRESS CITY STATE ZIP CODE SEX RACE DATE OF BIRTH PHONE NUMBER SOCIAL SECURITY NUMBER SIGNATURE DATE

2 United Distributors, Inc. Application Questionnaire Regarding Background for Employment Applicant Name: Position applying for: Check job location: Smyrna Savannah Albany Macon Augusta Brunswick Vidalia APPLICANT S STATEMENT: I understand that United Distributors, Inc. (Company) is committed to providing equal opportunity in all employment practices, including but not limited to selection, hiring, promotion, transfer, and compensation to all qualified applicants and employees without regard to age, race, color, national origin, sex, religion, handicap or disability, genetic information, citizenship status, service member status, or any other category protected by federal, state, or local law. I understand that I am required to disclose any criminal background information as part of my application and that disclosing criminal background information is not necessarily a bar to employment. I also understand that the Company will consider the nature of the crime, its seriousness, the substantial relation to the position s functions and qualifications, the number of occurrences, the applicant s age at the time of the crime, the time elapsed since the crime, the applicant s entire work and educational history, employment references and recommendations, and the business necessity of any exclusion when required by law. I FURTHER UNDERSTAND AND ACKNOWLEDGE, HOWEVER, THAT FAILURE TO DISCLOSE A CRIMINAL BACKGROUND OR DISHONESTY RELATED TO THE DISCLOSURE OF MY BACKGROUND, IF ANY, WILL CAUSE MY APPLICATION TO BE REMOVED FROM CONSIDERATION AND IT WILL NOT BE PROCESSED ANY FURTHER. I UNDERSTAND THAT DISCREPANCIES BETWEEN THE RESPONSES I PROVIDE ON THIS APPLICATION QUESTIONNAIRE REGARDING BACKGROUND FOR EMPLOYMENT AND THE CRIMINAL HISTORY REPORT AND/OR MOTOR VEHICLE REPORT THE COMPANY RECEIVES ABOUT ME WILL BE CONSIDERED A FAILURE TO DISCLOSE AND/ OR DISHONESTY IN MY APPLICATION AND CAUSE MY APPLICATION TO BE REMOVED FROM CONSIDERATION AND IT WILL NOT BE PROCESSED ANY FURTHER. I certify that the information given by me on this background questionnaire is and will be true and complete in all respects, and I agree that if the information is found to be false, misleading, or unsatisfactory in any respect (in the Company s judgment) that I will be disqualified from consideration for employment or subject to immediate termination if discovered after I am hired. I certify that I have received a separate written notification that the Company may obtain consumer reports (for example, criminal history, driving records, etc.) on me for use in connection with my application and, if I am hired, my employment. I authorize the Company to obtain such reports. DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THESE STATEMENTS. Date Applicant s Signature

3 ALL APPLICANTS MUST COMPLETE THE FOLLOWING QUESTIONS 1-8. READ EACH QUESTION CAREFULLY. FAILURE TO ANSWER PROPERLY COULD RESULT IN A DISCREPANCY WITH ANY CRIMINAL BACKGROUND OR MOTOR VEHICLE HISTORY. 1. Do you have any current charges pending against you? Yes No If you responded yes to the above question, please provide date(s), location, type (misdemeanor or felony) and details: 2. Have you ever plead guilty to a misdemeanor? Yes No If you responded yes to the above question, please provide date(s), location and details: 3. Have you ever plead guilty to a felony? Yes No If you responded yes to the above question, please provide date(s), location and details including the crime to which you pled: 4. Have you ever pled no contest or nolo to a misdemeanor? No Contest Nolo No If you circled No Contest or Nolo to the above question, please provide date(s), location and details including the crime to which you pled: [CONTINUE TO NEXT PAGE]

4 5. Have you ever plead no contest or nolo to a felony? No Contest Nolo No If you circled No Contest or Nolo to the above question, please provide date(s), location and details including the crime to which you pled: 6. Have you ever been convicted of a misdemeanor? Yes No If you responded yes to the above question, please provide date(s), location and details including charge convicted upon: 7. Have you ever been convicted of a felony? Yes No If you responded yes to the above question, please provide date(s), location and details including charge convicted upon: 8. Are you or have you ever been registered as a sex offender with any federal, state, or local government? Yes No If you responded yes to the above question, please provide date(s), location and details: **STOP AND READ CAREFULLY** Warehouse and Office/Administrative Positions: Do NOT complete the rest of this questionnaire. Only complete questions 1-8. Delivery, Draft, Merchandising, Sales, P.O.S. and Brand Development Positions: CONTINUE ON THE NEXT PAGE

5 ONLY APPLICANTS APPLYING FOR A POSITION THAT INVOLVES DRIVING MUST COMPLETE THE FOLLOWING QUESTIONS IF YOU ARE UNSURE WHETHER DRIVING IS A RESPONSIBILITY OF THE POSITION YOU ARE 9. APPLYING Accident FOR, Record PLEASE REFER for the TO past THE seven JOB DESCRIPTION (7) years. If WITH none\ THE APPLICATION YOU COMPLETED. DRIVING POSITIONS INCLUDE ALL: SALES, MERCHANDISING, DELIVERY, DRAFT, BRAND DEVELOPMENT, AND P.O.S. READ EACH QUESTION CAREFULLY. FAILURE TO ANSWER PROPERLY COULD RESULT IN A DISCREPANCY WITH ANY CRIMINAL BACKGROUND OR MOTOR VEHICLE HISTORY. 9. List all traffic convictions (other than parking tickets) for the last seven (7) years. Location Date Charge Penalty 10. Have you ever been charged with a DWI or DUI but were convicted of a lesser offense? Yes No If you responded yes to the above question, please provide dates and details: 11. Have you ever been required to attend driving school by a court of law? Yes No If you responded yes to the above question, please provide dates and details: **STOP AND READ CAREFULLY** Delivery and Draft Positions: Do NOT complete the rest of this questionnaire. Only complete questions Merchandising, Sales, P.O.S. and Brand Development Positions: CONTINUE ON THE NEXT PAGE

6 ONLY APPLICANTS APPLYING FOR A SALES, MERCHANDISING, P.O.S., OR BRAND DEVELOPMENT POSITIONS MUST COMPLETE THE FOLLOWING QUESTIONS THE ENTIRE DOCUMENT SHOULD BE COMPLETE IF YOU ARE APPLYING TO ONE OF THESE POSITIONS. READ EACH QUESTION CAREFULLY. FAILURE TO ANSWER PROPERLY COULD RESULT IN A DISCREPANCY WITH ANY CRIMINAL BACKGROUND OR MOTOR VEHICLE HISTORY. 12. List all accidents for the past seven (7) years. Last Accident Next Previous Next Previous Next Previous Dates Nature of Accident (Head-On, Rear-End, Etc.) Who Was At Fault 13. List all driver licenses or permits held in the past seven (7) years. If none, write none. If you do not know the license number or expiration date, write unknown. State License Issued License No. Type Approximate Dates You Operated a Vehicle Under this License License Expiration Date 14. Has your driver s license (any kind) ever been suspended, disqualified or revoked? Suspended Disqualified Revoked No If you circled Suspended, Disqualified or Revoked in response to the above question, list the type of license:, and state of issuance:. If you circled Suspended, Disqualified or Revoked in response to the above question, please provide dates and details: 15. Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No If you responded yes to the above question, please provide dates and details: [END OF DOCUMENT]