TRAFFIC AND LIGHTING SYSTEMS, L.L.C. CONSUMER AUTHORIZATION AND RELEASE In connection with TRAFFIC AND LIGHTING SYSTEMS, LLC considering me for employment, continued employment, promotion or reassignment, I authorize TRAFFIC AND LIGHTING SYSTEMS, LLC and/or its agent, SelectForce, Inc. to obtain a consumer report which may include information on my character, general reputation, personal characteristics, and mode of living from public record sources or through personal interviews with previous employers or associates. Public record check may include but is not limited to a criminal or felony background check, Workers Compensation Court check and a Motor Vehicle Report. I authorize, without reservation, any person or entity contacted by TRAFFIC AND LIGHTING SYSTEMS, LLC or its agent, SelectForce Inc. to furnish the above-stated information and I release any such person or entity from any and all liability for furnishing such information. I further release TRAFFIC AND LIGHTING SYSTEMS, LLC, its affiliated companies, their officers, employees and agents, and specifically, SelectForce, Inc. their affiliated companies, their officers, employees and agents from any liability and responsibility arising from preparation of said report. I understand that false or misleading statements made on this authorization, or made during the employment process, will disqualify me from consideration for employment or result in my immediate discharge if employed. By my execution hereof, I acknowledge I have been provided with a Consumer Disclosure advising me that a report will be requested and used for purpose of evaluating me for employment, continued employment, promotion or reassignment as an employee. Please Print NAME: First Middle Last Maiden (If Applicable) DOB SSN# - - DR.LIC# STATE ADDRESS: CITY: STATE: ZIP: How Long? PREVIOUS ADDRESS: CITY: STATE: ZIP: How Long? SIGNATURE: DATE: CONSUMER DISCLOSURE In connection with TRAFFIC AND LIGHTING SYSTEMS, LLC considering you for employment, continued employment, promotion or reassignment, TRAFFIC AND LIGHTING SYSTEMS, LLC may obtain a consumer report on you which may include information on character, general reputation, personal characteristics, and mode of living from public record sources or personal interviews with previous employers or associates. You have the right, upon written request, to receive a written description of the nature and scope of the investigation requested and a written summary of your rights under the Fair Credit Reporting Act. I HEREBY ACKNOWLEDGE RECEIPT: PRINT NAME DATE SIGNATURE
APPLICATION FOR EMPLOYMENT Traffic & Lighting Systems, LLC 1502 W. 37th Place Tulsa, OKlahoma 74107 WORKING FOR A DRUG FREE WORKPLACE In Compliance with Federal and State equal opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non job related disability, or any other protected group status. POSITION(S) APPLIED FOR: DATE: / / NAME: PRIMARY PHONE # ( ) ADDRESS: Last First Middle Street Apt. # City State Zip SOCIAL SECURITY NUMBER: DATE OF BIRTH: / / Do you have the legal right to work in the US? Yes No Have you ever applied for a job with us before? Yes No Will you be able to work out of town? Yes No Rate of Pay Expected $ (Hourly) / $ (Annually) If currently employed, why do you desire to make a change? How did you hear about us? Have you ever been convicted of or pled guilty ( no contest ) of a felony? Yes No If yes, then state the offense, date, court and place where convicted: Are you able to perform most task(s) with or without accommodations? If accommodation are needed< how would you perform most tasks< and with what accommodations? Why are you applying?
APPLICATION FOR EMPLOYMENT Please specify the highest grade you have completed: Last School Attended: EDUCATION Please provide any additional information such as special skills, training, management experience, equipment operation, or qualifications you feel will be helpful to us in considering your application. EXPERIENCE AND QUALIFICATIONS LIST ANY CURRENT OR UNEXPIRED LICENSES (Including Driver s License): STATE LICENSE # TYPE/CLASS RESTRICTIONS ENDORSEMENTS EXPIRATION DATE / / / / / / CERTIFICATIONS / TRAINING RECIEVED Current class of Driver s License? A B C D Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No Has any license, permit or privilege ever been suspended or revoked? Yes No EQUIPMENT EXPERIENCE EQUIPMENT YEARS/MONTHS OF OPERATION DESCRIBE WORK ACTIVITY Bucket Truck, Aerial Lifts, etc. Digger Derrick/Pole Cat Trencher Excavator Boring Machine Crane Skid steer Backhoe Pier Drilling
APPLICATION FOR EMPLOYMENT VIOLATIONS OF MOTOR VEHICLE LAWS AND ORDINANCES List all moving violations for the preceding 3 years: Date / / Violation Location Date / / Violation Location List courses of training that will help you as a driver: DRIVING EXPERIENCE Type of Equipment: CLASS OF EQUIPMENT (Van, Tank, Flat) From To Approx. # of Miles (Total) Straight Truck: Tractor / Trailer: Doubles / Triples: Other: Can you drive a standard/manual transmission? Yes No COMMERICAL MOTOR VEHICLE ACCIDENTS I certify that the following is true and accurate list of all commercial vehicle accidents and any Fatalities and Personal Injuries as a result of said accident in accordance with FMCSA 391.27(7) for the 3 years preceding this application. STATEMENT OF COMMERCIAL VEHICLE LICENSE SUSPENSIONS I certify that the following is a true and complete list of facts and circumstances of any denial, revocation, or suspension of any license, permit, or privilege to operate a commercial vehicle. If no violations are listed above, I certify that I have not had my commercial driver s license denied, revoked, suspended or any license, permit or privileges to operate a commercial vehicle in accordance with FMCSA 391.21(9) Signature: Date: / /
PREVIOUS EMPLOYERS Start with most current employer. List employers for the previous 10 years. All employers for the last 3 years will be contacted. Attach additional sheet if necessary. REFERENCES GIVE THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR. Name: Relationship: Phone: ( ) Name: Relationship: Phone: ( ) Name: Relationship: Phone: ( )
APPLICANT S ADDRESSES FOR PRECEDING 3 YEARS PRIOR TO APPLICATION Street Address City State Zip Street Address City State Zip Street Address City State Zip I certify that the above information is correct and accurate to the best of knowledge in accordance with 391.21(3). Signature: Date: / / PLEASE READ THE FOLLOWING CERTIFICATION CAREFULLY BEFORE SIGNING JOB APPLICANT S CERTIFICATION I certify that the information given by me in this application is true in all respects, and I agree that if the information given is found to be false in any way, it shall be considered sufficient reason for denial of employment or discharge. I authorize the use of any information in this application to verify my statements, and accept as indicated above, I authorize past employers, all references, and any other persons to answer all questions asked concerning my ability, character, reputation, and previous education or employment record. I release all such persons from any liability damages on account of having furnished such information. I consent to such investigations that this employer may make regarding driving records, law enforcement records, credit reports and my general background. I further understand that all applicable portions of this application must be completed or I will be ineligible for consideration for the position for which I am applying. I understand that turning in this employment application or the granting of an interview is not indicative of establishment of employment between this employer and myself nor for the providing of any benefits. No promises regarding employment have been made to me, and I understand that no promise or guarantee of employment for any specific length of or under any specified circumstances shall be binding unless made in writing by or with the express written consent and authorization of the President/Owner. If an employment relationship is established, I understand that I have the right to terminate my employment at any time and for any reason and that this employer retains the same right. I understand that, if I am initially offered a position of employment, I may be required to submit to drug and/or alcohol tests which are a condition of employment and that refusal to submit to such tests when asked by this employer shall be sufficient reason for denial for employment or discharge. I understand that if employed, the policies and rules, which are issued by this Traffic & Lighting Systems, LLC, are not conditions of employment and that this employer may revise policies or procedures, in whole or in part, unilaterally at any time. IMPORTANT IF YOU DO NOT UNDERSTAND, OR IF YOU DISAGREE WITH ANY PORTION OF THE ABOVE CERTIFICATION, DO NOT SIGN BEFORE DISCUSSING WITH THIS EMPLOYER This certifies that this application was completed by me, and that all entries on it are true and complete to the best of my knowledge. Applicant s Signature: Date: / /