Application to be a STEP Worksite

Transcription

1 Application to be a STEP Worksite NAME: : Home Address: City: State: Zip Code: address: Home Phone: Work phone: Cell Phone: of Birth: Gender: Male Female Ethnicity: Caucasian: Hispanic/Latino: African American: Asian: Other: Internship Site: Job Title: Length of Employment: Supervisor s Name: Internship Site Address: Have you ever been convicted of a crime? If yes, please explain Driver s License Number: (attach photocopy of license) Car Insurance Company: (attach photocopy of insurance card) Vehicle Make, Model and Year: Tag Number: PROFESSIONAL INFORMATION: Why would you like to work with a youth? Can you commit to meet with your assigned youth, on site for at least four hours per week? What would the ideal internship schedule be for a youth at your site? What possible duties would be offered to your assigned youth? Do you speak any language other than English? 1

2 REFERENCES: Please list the names, addresses and phone numbers of two people for character references. List only people you have known you for at least one year. Name: Address: City: State: Zip Code: Phone(s): Relationship: Name: Address: City: State: Zip Code: Phone(s): Relationship: Please read this carefully before signing: STEP Mentoring Program appreciates your interest in becoming a professional mentor. Please initial each of the following: I agree to follow all mentoring program guidelines and understand that any violation will result in suspension and/or termination of the mentoring relationship. I understand I must return all of the following completed items along with this application and that any incomplete information will result in the delay of my application being processed: 1. Copy of my valid driver s license and proof of auto insurance 2. Criminal Record Screening Release forms, including Child Abuse and Sexual Offender Screening 3. Motor Vehicle Check Release form (Center For Family Services Agency form) By signing below, I attest to the truthfulness of all information listed on this application and agree to the above terms and conditions. 2

3 Vision, Hope, and Strength for a Better Life VOLUNTEER MOTOR VEHICLE REPORT RELEASE I am applying to volunteer or employment with The Center For Family Services, Inc. I acknowledge that I have been notified by CFS that a Motor Vehicle Record Check will be run to determine if I am eligible to drive for the Agency. I understand that this report will be used to evaluate me for possible eligibility regarding this or any other CFS driving position. I also understand that this consent form allows for the ongoing Motor Vehicle Record Checks per CFS policy, if I am volunteering or employed in a CFS driving position. The Fair Credit Reporting Act entitles me to know if an adverse volunteer/employment decision is made based on this information obtained from a Consumer Reporting Agency. If any adverse volunteer/employment decision is made based on this information, I will be advised. I will also be given the name of the agency or source which provided the information, a copy of the information (Motor Vehicle Report), and a summary of my rights under the Fair Credit Reporting Act. I,, give my permission to allow (Print Full Name) Center for Family Services, Inc., to obtain a Motor Vehicle Report on my behalf and to recheck my MVR ongoing per Agency policy if I am volunteering or employed in a CFS driving position. Please Print Clearly Full Name Position Applied For/Current Position Social Security Number Program Full Address City State, Zip Have you been a licensed driver for at least three years? YES NO Have you been a licensed driver for at least six years? YES NO Driver s License Number: State Driver s License issued: State of Residence: Do you currently have a graduated or suspended license? YES NO I acknowledge the above information is current and correct. I understand that if the information is found to be not correct, my application for volunteer or employment may be denied or, if currently volunteering or hired, I may be subject to discipline, up to and including termination: : : Supervisor: Submitted to HR: Revised 7/08 AF

4 CFS CRIMINAL RECORD REPORT DISCLOSURE AND RELEASE FOR MENTORS, VOLUNTEERS AND INTERNS In connection with your application for mentoring, volunteering or internship an investigative consumer report and consumer reports, which may contain public information, may be requested from HireRight. Such reports may contain public record information. You have the right to receive, upon your written request within a reasonable period of time, (not to exceed 30 days) a complete and accurate disclosure of the nature and scope of the investigation requested. You have the right to make a request to HireRight, upon proper identification, to request the nature and substance of all information in its files on you at the time of your request, including the sources of information, and the recipients of any reports on you that USIS has previously furnished within the two year period preceding your request. HireRight may be contacted by mail at P.O. Box 33181, Tulsa, OK 74153, or by phone at Attached to this disclosure is a written summary of your rights under the Fair Credit Reporting Act (FCRA) as prepared by the Federal Trade Commission. I AUTHORIZE, WITHOUT RESERVATION, HIRERIGHT TO FURNISH A CONSUMER OR INVESTIGATIVE CONSUMER REPORT ABOUT ME TO CENTER FOR FAMILY SERVICES, INC FOR EMPLOYMENT RELATED PURPOSES. HireRight is authorized to disclose all information obtained to CENTER FOR FAMILY SERVICES, INC. for the purpose of making a determination as to my eligibility for mentoring, volunteering or internship or any other lawful purpose. If brought on as a mentor, this authorization shall remain on file and shall serve as ongoing authorization for the procurement of investigative consumer reports and consumer reports at any time during my mentoring, volunteering or internship or contract period. By signing below, I certify that I have read and understand this release and that I executed this release voluntarily and with the knowledge that the information being released could affect my being a mentor, volunteer or intern. This release is valid for all federal, state, county and local agencies, authorities, and governments. Please Print Clearly Position Program Social Security Number of Birth Last Name First Name Middle Name Street Address City State Zip County I acknowledge that the above information is current and correct. Supervisor: Submitted to HR: Revised 4/12 LP

5 Para informacion en espanol, visite o escribe a la FTC Consumer Response Center, Room 130-A 600 Pennsylvania Ave. N.W., Washington, D.C 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 Response Center, Room 130-A, Federal Trade Commission, 600 Pennsylvania Ave. 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 identify 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, by September 2005 all consumers will be 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.

6 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 remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at OPTOUT ( ). 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. Federal enforcers are: TYPE OF BUSINESS: Consumer reporting agencies, creditors and others not listed below National banks, federal branches/agencies of foreign banks (word "National" or initials "N.A." appear in or after bank's name) Federal Reserve System member banks (except national banks, and federal branches/agencies of foreign banks) Savings associations and federally chartered savings banks (word "Federal" or initials "F.S.B." appear in federal institution's name) Federal credit unions (words "Federal Credit Union" appear in institution's name) State-chartered banks that are not members of the Federal Reserve System Air, surface, or rail common carriers regulated by former Civil Aeronautics Board or Interstate Commerce Commission Activities subject to the Packers and Stockyards Act, 1921 CONTACT: Federal Trade Commission: Consumer Response Center - FCRA Washington, DC Office of the Comptroller of the Currency Compliance Management, Mail Stop 6-6 Washington, DC Federal Reserve Board Division of Consumer & Community Affairs Washington, DC Office of Thrift Supervision Consumer Complaints Washington, DC National Credit Union Administration 1775 Duke Street Alexandria, VA Federal Deposit Insurance Corporation Consumer Response Center, 2345 Grand Avenue, Suite 100 Kansas City, Missouri Department of Transportation, Office of Financial Management Washington, DC Department of Agriculture Office of Deputy Administrator - GIPSA Washington, DC