2.  Conviction Date:     Crime:    Law Enforcement Agency:    

Court Jurisdiction:    Disposition:   

Are you now, or have you ever been a defendant in a civil proceeding?  Yes No   (if yes, give details below)

 

SECTION VI.  EMPLOYMENT BACKGROUND:

List all employers.  Start with your present or most recent job first.  Include military service, periods of self-employment, and full-time volunteer activities.  

1.  Name of Employer:    Your Position:   

Employment Dates:  (from-to)   Primary Duties:    

Address:    Reason for Leaving: 

Supervisor:    Supervisor's Phone: 

 

2.  Name of Employer:    Your Position:   

Employment Dates:  (from-to)   Primary Duties:    

Address:    Reason for Leaving: 

Supervisor:    Supervisor's Phone: 

Name and Current Phone Number of Co-Worker: 

 

3.  Name of Employer:    Your Position:   

Employment Dates:  (from-to)   Primary Duties:    

Address:    Reason for Leaving: 

Supervisor:    Supervisor's Phone: 

Name and Current Phone Number of Co-Worker: 

 

4.   Name of Employer:    Your Position:   

Employment Dates:  (from-to)   Primary Duties:    

Address:    Reason for Leaving: 

Supervisor:    Supervisor's Phone: 

Name and Current Phone Number of Co-Worker: 

 

If you are presently employed, may we contact your employer?  Yes No

Have you ever been discharged or asked to resign by an employer?   Yes No
If yes, explain fully.

Please identify any periods of unemployment during the last 10 years.  State reasons for Unemployment:  

 

SECTION VII.  REFERENCES:

List four personal references who are not relatives.  Include all pertinent contact information. 

1.  Name:     Address: 

2.  Name:     Address: 

3.  Name:     Address: 

4.  Name:     Address: 

 

SECTION VIII.  MILITARY:

Have you served in any branch of the United States military?  Yes No   If yes, what branch?  Army Navy Air Force Marines N/A

Date of service:  (from-to)  Highest Rank Held:   

What was your MOS?  Description  

 Other Period of Active Service?  Yes No   If so, list branch and dates:   

Describe duties, special training, awards/decorations:  

Type of Discharge:    

Any current military classification?  Yes No
If yes, explain below:

 

SECTION IX.  MISCELLANEOUS:

Is there any factor not covered by questions in this document, which should be brought to the attention of background investigators?  please explain.  

Can you type?  Yes No   If yes, words per minute:    Are you computer literate?  Yes No

If computer literate, list the software you are proficient at: 

Please list skills, other qualifications, or other experiences that add to your value for this position.  List other Special Training (e.g., electronics, accounting, welding, computers, security, forklift operator, mechanical, etc.):

Emergency Contact Information.  In case of an emergency, contact:

1.  Full Name:    Relationship:    Telephone: 

2.  Full Name:    Relationship:    Telephone: 

Drug Use.  Select "yes" for all that apply for your personal use, purchase, possession or sale.  If applicable, report the number of times used/sold, and the last time used/sold.

HALLUCINOGENIC DRUGS:

1.  Marijuana            Yes No    Number of times used/sold:     Last time used/sold: 

2.  LSD                    Yes No    Number of times used:     Last time used: 

3.  PCP                    Yes No    Number of times used:     Last time used: 

STIMULANTS:

1.  Cocaine              Yes No    Number of times used:     Last time used:      

2.  Amphetamines    Yes No    Number of times used:     Last time used: 

DEPRESSANTS:

1.  Barbituates         Yes No    Number of times used:     Last time used:    

DEPRESSANTS   Yes No    Number of times used:     Last time used: 

2.  Tranquilizers       Yes No    Number of times used:     Last time used: 

NARCOTICS:

1.  Opium                Yes No    Number of times used:     Last time used: 

2.  Morphine           Yes No    Number of times used:     Last time used: 

3.  Heroin                Yes No    Number of times used:     Last time used:  .  .  

SUBSTANCE/CHEMICAL ABUSE:

1.  Glue Sniffing      Yes No    Number of times used:     Last time used: 

2.  Sniffing Paint     Yes No    Number of times used:     Last time used:  Thinner, Solvent                                                                                                                                          and/or Sprays

ANY NOT LISTED:

1.  Indicate             Yes No    Number of times used:     Last time used:  names of any others

In addition to the above, have you grown, cultivated, transported, loaned, borrowed, or in any way possessed or used or abused drugs?  Yes No   If yes, please explain 

PERSONAL STATEMENT:  If necessary, please use the following space to clarify anything listed or marked on this application:

 

PLEASE READ BEFORE AGREEING

Notice of investigative Consumer Report.  In applying for employment with NASS, Inc., I understand that NASS Inc. may obtain a consumer report (including a possible investigative consumer report based on personal interviews) about me from a consumer reporting agency.  I hereby acknowledge receiving disclosure of this fact and I acknowledge that I have executed one or more authorizations to consumer reporting agencies and certain others (e.g., former employers) to release information concerning me.  The reports may include information as to my character, general reputation, personal characteristics, and mode of living whichever are applicable.  The reports also may include, but are not not limited to, my credit history, criminal records involving arrests and/or convictions, motor vehicle and/or driver's license records, drug test results, references and copies of my personnel file from prior employers.  I also understand that I have the right to make a written request within a reasonable period of time for a complete and accurate disclosure of the nature and source of the consumer report. 

Information from Third Parties.  I authorize NASS Inc. to request and receive responses and information concerning me in addition to the consumer report (including a possible investigative consumer report based on personal interviews).  I understand that such responses and information may be obtained from sources which include, but are not limited to, personal (e.g., family members, friends, neighbors, other personal acquaintances), consumer reporting agencies, schools business/professional organizations/associations, law enforcement authorities, governmental agencies, present and past employers and branches of military service.  I acknowledge that I am authorizing any such third parties to furnish NASS Inc. with responses and information concerning me, and I hereby release NASS Inc. and/or its agents from any and all liability and responsibility arising out of the release, request, receipt, or use of such responses and information.

Truthfulness of Information Furnished.  I certify that the information which I have furnished on this application is true and complete, and I understand that any misrepresentation will be sufficient cause for my not being employed or for dismissal if employed.  I also understand that employment is subject to satisfactory academic and past employment record. 

Authorization to Release Information and Records.

I hereby authorize the following organizations, individuals, and entities to furnish NASS Inc. or its agents with any and all available information and copies of records/transcripts pertaining to me, my activities, and/or status for the purpose of consideration for employment with NASS Inc:

• Present and past employers

• Schools, colleges, universities, or other institutions of learning

• Law enforcement agencies and custodians of court records

• Custodians of state records

• Branches of military service

• Credit bureaus of financial reporting institutions

• Individuals who serve as references

I understand and voluntarily agree that I may be requested by the company to take a drug screen at any time as a condition of initial or continued employment, and that failure to take such a test or a positive test result may result in my dismissal, as applicable by state law. 

If hired, I understand I will be required to serve a one hundred and eighty day probationary period.  This form of authorization shall be considered as effective and valid as the original.  I hereby hold harmless form liability NASS Inc. and any other person(s) or agency and their employees and agents who may provide or discuss pertinent information in conjunction with the background investigation.

I herby AGREE DISAGREE to all of the stipulations of this form.  Today's Date: