APPLICATION FOR EMPLOYMENT

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1 APPLICATION FOR EMPLOYMENT OPARC 9029 Vernon Avenue Montclair, CA (PLEASE PRINT) Position(s) applied for Date of application / / Name Social Security # LAST FIRST MIDDLE Address STREET CITY STATE ZIP Home Phone # ( ) Best time to call is Message Phone ( ) In Case of Emergency Notify NAME ADDRESS PHONE NO. How Did You Learn About Us? Advertisement Friend Walk-in Employee Relative Other Name of source (if applicable) If you are under 18 can you provide required proof of your eligibility to work? Yes No Have you ever filed an application with us before? Yes If yes, give date Have you ever been employed here before? Yes Are you legally eligible for employment in this country? Yes Are you currently employed? Yes On what date would you be available for work May we contact your present employer? Yes If yes, work number ( ) Are you able to meet attendance requirements? Yes Have you had any convictions in the last (10) years? Yes If yes, please explain Conviction will not necessarily disqualify an applicant from employment. As a Community Care Licensed Facility (California Code of Regulations, Title 22, Division 06, Section 80019, Adult Day Care) fingerprint clearance is required for employment. Clearance may be denied by the Department of Social Services if your record includes certain misdemeanor convictions. Exemptions may be considered through the Department of Social Services. Note to Applicants: DO NOT ANSWER THESE QUESTIONS UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING. Are you capable of performing in a reasonable manner the activities involved in the job or occupation for which you have applied? Yes Job Description for POSITION was reviewed with applicant by: INTERVIEWER A description of the activities involved in such a job or occupation is attached and/or was reviewed with me on: (date) Yes We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, creed, color, age, sex, religion or national origin, gender, marital status, sexual orientation, or any other legally protected status. Page 1 of 6

2 Educational Background Name and Location of School Circle Last Year Completed Did You Graduate? Elementary School Yes High School Yes College Yes Graduate School or Yes Trade/Business School Subjects Studied and Degree(s) Received Employment History Please give accurate, complete full-time and part-time employment record. Provide the following information for your past and current employers, assignments or volunteer activities, starting with the most recent (use additional sheets if necessary). Explain any gaps in employment in comments section below. Employer Telephone Dates Employed Summarize the type of work ( ) From To performed and job responsibilities Address, City, State, Zip Job Title Immediate Supervisor and Title Hourly Rate/Salary Starting Ending Reason For Leaving $ $ Employer Telephone Dates Employed Summarize the type of work ( ) From To performed and job responsibilities Address, City, State, Zip Job Title Immediate Supervisor and Title Hourly Rate/Salary Starting Ending Reason For Leaving $ $ Employer Telephone Dates Employed Summarize the type of work ( ) From To performed and job responsibilities Address, City, State, Zip Job Title Immediate Supervisor and Title Hourly Rate/Salary Starting Ending Reason For Leaving $ $ Employer Telephone Dates Employed Summarize the type of work ( ) From To performed and job responsibilities Address, City, State, Zip Job Title Immediate Supervisor and Title Hourly Rate/Salary Starting Ending Reason For Leaving $ $ COMMENTS (Include explanation of any gaps in employment) Page 2 of 6

3 Skills and Qualifications Describe any special training, skills, licenses and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying Specialized Skills/Knowledge Calculator Excel Production/Machinery Operated: Typewriter Access - words per minute Word Other (list): PC Other Additional Information Exclude information which would reveal sex, race, religion, national origin, age, color, disability or other protected status. List Professional, trade, business, or civic associations and any offices held. List special accomplishments, publications, awards, extra-curricular activities and interests. State any additional information you feel may be helpful to us in considering your application. INDICATE ANY FOREIGN LANGUAGES YOU CAN SPEAK, READ AND/OR WRITE SPEAK READ WRITE FLUENT GOOD FAIR MILITARY Did you serve in the U.S. Armed Forces? Yes Describe any training received relevant to the position for which you are applying. If Yes in what Branch? Type of Discharge? Page 3 of 6

4 References: Provide the names of three persons not related to you, who you have known for at least two years. 1. Name Phone ( ) Address 2. Name Phone ( ) Address 3. Name Phone ( ) Address Business/Relationship Years Applicant s Statement: The information provided in this Application for Employment is true, correct, and complete. I understand that if I am employed, any misrepresentation or material omission made by me on this application will be sufficient cause for immediate discharge from OPARC s service, whenever it is discovered. I understand that if I am employed, the terms and conditions of my employment will be governed by a Personnel Manual. I agree that OPARC has the legal right to modify the terms and conditions of employment unilaterally at any time. I give OPARC the right to contact and obtain information from all references, employers, educational institutions and to otherwise verify the accuracy of the information contained in this application. I hereby release from liability OPARC and its representatives for seeking, gathering and using such information and all other persons, corporations or organizations for furnishing such information. If OPARC decides to engage an investigative consumer reporting agency to report on my credit and personal history I authorize it to do so. If a report is obtained OPARC must provide, at my request, the name of the agency so I may obtain from them the nature and substance of the information contained in the report. I understand that OPARC does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by local, state or federal law. This application is current for only 60 days. At the conclusion of this time, if I have not heard from OPARC and still wish to be considered for employment, it will be necessary to fill out a new application. If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice. OPARC reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no representative of OPARC, other than the President/CEO, has the authority to make any assurances to the contrary. I further understand that any such assurances must be in writing and signed by the President/CEO. I understand that it is OPARC policy not to refuse to hire a qualified individual with a disability because of that person s need for a reasonable accommodation as required by the ADA. I also understand that if I am hired, I will be required to provide proof of identity and legal work authorization. I understand that I am required to abide by all OPARC rules and regulations. Any and all job offers made by OPARC are contingent on applicant passing a job-related physical examination, which includes a TB test and drug screen. I represent and warrant that I have read and fully understand the foregoing and seek employment under these conditions. Signature of Applicant Date / / f:\admin\forms\employapp-s:9/98 Page 4 of 6 CR7/10

5 SUPPLEMENT TO OPARC APPLICATION FOR EMPLOYMENT Name (print) Part I Specific Experience as a Caregiver How many years of experience do you have working directly with people who have disabilities? as a paid staff member as a volunteer or family member Do you have any experience in working with people as a caregiver, but the people you cared for were NOT people with disabilities? (For example, you might have cared for an elderly parent, a chronically sick relative, etc.) If you have any such experience, describe it below. Part II Transportation (Note: Some OPARC positions require the ability to drive either company vehicles or the employee s own vehicle. The following information will help OPARC in determining the specific positions for which you qualify. Your answers will NOT disqualify you from positions that do not require driving.) Would you be able to use your own car during the work day to transport clients? ο Yes ο No In order to use your car on OPARC business, it must first pass a safety inspection (at OPARC expense). Do you foresee any difficulty in getting your vehicle to pass a safety inspection? Yes Do you foresee any difficulty in ensuring your vehicle for liability coverage at the $100,000/$300,000/$50,000 level? [Note: if you accept a position that requires this level of coverage, OPARC will pay a monthly stipend of $30 in addition to your regular wages.] Yes When did you first acquire a driver s license? Year Driver s License # Has your driver s license ever been suspended or revoked? Yes If Yes, please explain and indicate what year the action occurred. Have you had an accident that was your fault or three or more moving violations within the last three years? Yes If Yes, please provide details. [NOTE: This is part of the official application form. Your signature at the bottom of the Applicant s Statement indicates that all information provided on this form is true and correct.] f:\admin\forms\applicationsupplement-s:7/10 Page 5 of 6

6 DISCLOSURE AND AUTHORIZATION TO CONDUCT BACKGROUND CHECK [IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING AUTHORIZATION] As part of our evaluation process for employment, promotion, retention, contingent or temporary staffing, consulting, sub-contract work, or volunteer work, OPARC "COMPANY" may obtain information about you for employment purposes from a third party consumer reporting agency. Thus, you may be the subject of a consumer report and/or an investigative consumer report (background check) which may include information about your character, general reputation, personal characteristics, and/or mode of living, and which may involve personal interviews with sources such as your associates, colleagues, neighbors or friends. These reports may contain information regarding your criminal history, Social Security verification, motor vehicle records ( driving records ), verification of your education or employment history, or other background information. Credit history may be requested, but only where such information is substantially related to the duties and responsibilities of the position for which you are applying. You have the right, upon written request made within a reasonable time, to learn whether a consumer report has been requested about you. You also have the right to obtain a disclosure of the nature and scope of any investigative consumer report and to request a copy of your report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your education and/or employment history. All reports referenced in this document will be obtained from Frasco Profiles, 215 W. Alameda Avenue, Burbank, CA 91502, Phone: (800) , Fax: (818) , The scope of this notice and authorization is all-encompassing, allowing COMPANY to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and throughout the course of your employment to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report. STATE SPECIFIC INFORMATION (applies to residents of the noted state only): New York and Maine applicants or employees only: You have the right to inspect and receive a copy of any investigative consumer report requested by COMPANY by contacting the consumer reporting agency identified above directly. You may also contact COMPANY to request the name, address and telephone number of the nearest unit of the consumer reporting agency designated to handle inquiries, which COMPANY shall provide within 5 days. New York applicants or employees only: Upon request, you will be informed whether or not a consumer report was requested by COMPANY, and if such report was requested, informed of the name and address of the consumer reporting agency that furnished the report. By signing below, you also acknowledge receipt of Article 23-A of the New York Correction Law. Oregon applicants or employees only: Information describing your rights under federal and Oregon law regarding consumer identity theft protection, the storage and disposal of your credit information, and remedies available should you suspect or find that COMPANY has not maintained secured records will be provided upon request. Washington State applicants or employees only: You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act. Utah applicants only: The employer cannot ask for your date of birth, driver s license number, or Social Security Number until either a confidential offer of employment or at the time the background check will be run. This information is being sought now in conjunction with your background check. 1

7 APPLICANT IDENTIFICATION INFORMATION This information is being collected for the sole purpose of completing your background check. No information provided below will be used as hiring criteria. For information regarding Frasco Profiles' privacy policy, please refer to PLEASE PRINT IN BLOCK LETTERS IN BLACK OR BLUE INK. Last Name First Name Middle Name Other Names Used in Past 10 Years: Social Security Number: Month of Birth: Day of Birth: Year of Birth: Drivers License Number*: State of Drivers License Number: Prior Drivers License Numbers & States of Issue: If no DL, State Issued ID Card # & State of Issue: Present Street Address: City: State: Zip Code: Past Address if Above Less than 1 Year City: State: Zip Code: Phone Number w/area Code: Alternate Phone Number w/area Code: Address: Are you currently employed? Yes If yes, may we contact your current employer to verify your employment? Yes *Louisiana driving history information will be obtained by American Driving Records 2

8 ACKNOWLEDGMENT AND AUTHORIZATION I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION on page 1 of this document and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of consumer reports and/or investigative consumer reports by COMPANY at any time after receipt of this authorization and throughout my employment, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, court administrator, state or federal agency, institution of learning, school or university (public or private), information service bureau, employer, credit bureau, department of motor vehicles or driver licensing bureau, military branch or National Personnel Records Center, sex offender registry, licensing board, workers' compensation administrator, personal or professional reference to furnish any and all background information requested by Frasco Profiles, 215 W. Alameda Avenue, Burbank, CA 91502, Phone: (800) , Fax: (818) , another outside organization or individual acting on behalf of Frasco Profiles, and/or COMPANY itself. I agree that a facsimile ( fax ), electronic or photographic copy of this Authorization shall be as valid as the original. New York applicants or employees only: By signing below, you acknowledge receipt of Article 23-A of the New York Correction Law. Minnesota and Oklahoma applicants or employees only: Please check this box if you would like to receive a copy of a consumer report if one is obtained by COMPANY. California applicants or employees only: By signing below, you also acknowledge receipt of the Additional Notice to California Applicants. Please check this box if you would like to receive a copy of an investigative consumer report or consumer credit report at no charge if one is obtained by COMPANY whenever you have a right to receive such a copy under California law. Full Name (print): Other Full Names used in past ten years: Social Security Number: Signature: Date: 3

9 Para informacion en espanol, visite o escribe a la Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC A Summary of Your Rights Under the Fair Credit Reporting Act The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, D.C You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment or to take another adverse action against you must tell you, and must give you the name, address, and phone number of the agency that provided the information. You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your file disclosure ). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if: a person has taken adverse action against you because of information in your credit report; you are the victim of identity theft and place a fraud alert in your file; your file contains inaccurate information as a result of fraud; you are on public assistance; you are unemployed but expect to apply for employment within 60 days. In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See for additional information. You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender. You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See for an explanation of dispute procedures. Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate. Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old. Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access. You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to You may limit prescreened offers of credit and insurance you get based on information in your credit report. Unsolicited prescreened offers for credit and insurance must include a toll-free phone number you can call if you choose to 4

10 remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court. Identity theft victims and active duty military personnel have additional rights. For more information, visit States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. For information about your federal rights, contact: TYPE OF BUSINESS: 1.a. Banks, savings associations, and credit unions with total assets of over $10 billion and their affiliates. b. Such affiliates that are not banks, savings associations or credit unions also should list in addition to the CFPB: 2. To the extent not included in item 1 above: a. National banks, federal savings associations, federal branches and federal agencies of foreign banks. b. State member banks, branches and agencies of foreign banks (other than federal branches, federal agencies, and Insured State Branches of Foreign Banks), commercial lending companies owned or controlled by foreign banks, and organizations operating under section 25 or 25A of the Federal Reserve Act. c. Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured state savings associations. d. Federal Credit Unions CONTACT: a. Consumer Financial Protection Bureau 1700 G Street NW, Washington, DC 2006 b. Federal Trade Commission: Consumer Response Center FCRA Washington, DC a. Office of the Comptroller of the Currency Customer Assistance Group, 1301 McKinney Street, Suite 3450, Houston, TX b. Federal Reserve Consumer Help Center P.O. Box 1200 Minneapolis, MN c. FDIC Consumer Response Center 1100 Walnut Street, Box #11, Kansas City, MO d. National Credit Union Association Office of Consumer Protection (OCP) Division of Consumer Compliance and Outreach(DCCO) 1775 Duke Street, Alexandria, VA Air Carriers Asst. General Counsel for Aviation & Enforcement Proceedings Aviation Consumer Protection Division Department of Transportation 1200 New Jersey Avenue,SE Washington, DC Creditors Subject to Surface Transportation Board Office of Proceedings, Surface Transportation Board Department of Transportation 395 E Street, S.W. Washington, DC Creditors Subject to Packers and Stockyards Act, 1921 Nearest Packers and Stockyards Administration area supervisor. 6. Small Business Investment Companies Associate Deputy Administrator for Capital Access United States Small Business Administration 406 Third Street, SW, 8 th Floor, Washington, DC Brokers and Dealers Securities and Exchange Commission 100 F St. NE Washington, DC Federal Land Banks, Federal Land Bank Associations, Federal Intermediate Credit Banks, and Production Credit Associations Farm Credit Administration 1501 Farm Credit Drive McLean, VA Retailers, Finance Companies, and All Other Creditors Not Listed Above FTC Regional Office for region in which the creditor operates or Federal Trade Commission: Consumer Response Center-FCRA Washington, DC

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