CHILDCARE TEAM

HIGH SCHOOL

COLLEGE

TRADE, BUSINESS, OR CORRESPONDENCE SCHOOL

DO NOT ANSWER ANY OF THE QUESTIONS IN THIS BOX UNLESS THE EMPLOYER HAS CHECKED THE BOX PRECEDING A QUESTION, THEREBY INDICATING THAT THE INFORMATION IS REQUIRED FOR A BONA FIDE OCCUPATIONAL QUALIFICATION, OR DICTATED BY NATIONAL SECURITY LAWS, OR IS NEEDED FOR OTHER LEGALLY PERMISSIBLE REASONS. THE INFORMATION DISCLOSED WILL NOT BE USED TO DISCRIMINATE AGAINST THE APPLICANT DURING THE HIRING PROCESS FOR ANY REASONS RELATING TO RACE, COLOR. SEX, RELIGIOUS AFFILIATION, NATIONAL ORIGIN, GENDER, OR ANY DISABILITY.

This question is being asked because the job for which you are applying is considered a "security-sensitive" job. requiring a very high level of trust, such as any position in which the employee handles currency, has access to a job-related computer terminal, has access to a master key, or works in an area which has been designated as a security-sensitive area. Answering yes to this question will not constitute an automatic rejection of employment. The date of the offense, the seriousness and nature of the violation, rehabilitation, and position applied for will all be considered. If your record was expunged, sealed or set aside, you may answer "no" to the above question.

Any information voluntarily disclosed in the following question will only be used by the employer to determine the extent of any employer-provided accommodations that may be necessary for the applicant under the American with Disabilities Act; the information disclosed will not be used to discriminate against the applicant during the hiring process for any reasons relating to disabilities, health problems, or medical conditions.

Are you able to perform each of the following job functions with or without an accomodation?

"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 or 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.

I understand that a consumer credit report or criminal records check may be necessary prior to my employment. If such reports are required, I understand that, in compliance with federal law, the company will provide me with a written notice regarding the use of these reports and will also obtain a separate written authorization from me to consent to these reports. I also understand that a poor credit history or conviction will not automatically result in disqualification from employment."

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Dis¬abilities Act (ADA) and other relevant federal and state laws.

In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire.