NAME: __________________________________
ADDRESS: ______________________________
CITY/STATE/ZIP: ________________________
DATE OF BIRTH: ________________________
CELL PHONE: ___________________________
HOME PHONE: __________________________
SOCIAL SECURITY#: ____________________
DRIVERS LICENSE #: ____________________
STATE ISSUED: __________________________
Have you ever pled guilty to, been convicted of or been granted a deferred adjudication for any felony? _______
If yes, please include year and explanation:
___________________________________________________________
Have you ever pled guilty to, been convicted of or been granted a deferred adjudication for any misdemeanor (excluding minor traffic violations)? _______
If yes, please include year and explanation:
___________________________________________________________
Pre-Employment Screening Consent
By agreeing the applicant ("Applicant") hereby acknowledges, agrees and irrevocably consents to the following:
- All information provided by Applicant in this Pre-Employment Screening Consent and the Employment Application submitted by the Applicant are true and complete.
- Parker Loss Consultants are authorized to conduct and use for employment purposes a comprehensive criminal background investigation which may include, but may not be limited to, obtaining a "consumer report" from a "consumer reporting agency" (as such terms are defined in the federal Fair Credit Reporting Act).
- Parker Loss Consultants will request from a consumer reporting agency a consumer report for employment purposes because clients of Parker Loss Consultants require verification of employee criminal history, employee will have regular access to the confidential and proprietary information of Parker Loss Consultants's clients and/or employee will be a named signatory on the bank account(s) of certain of Parker Loss Consultants's clients. The consumer report will include information from law enforcement agencies, state agencies and public records information, such as criminal convictions and driving records. The consumer report will not include credit related information.
- If the Applicant is hired, Parker Loss Consultants is authorized to redo and update the comprehensive criminal background investigation (including any consumer report) from time to time and at any time during the Applicant's employment.
- If Parker Loss Consultants uses information from a consumer report in whole or in part in making an adverse employment decision, the Applicant will receive a notice about the consumer reporting agency, confirmation that the consumer reporting agency is not responsible for any adverse action taken and that the consumer reporting agency is unable to provide specific reasons for the adverse action, and a notice about the Applicant's rights under applicable law to obtain a free copy of the consumer report from the consumer reporting agency within 60 days and right to dispute the accuracy or completeness of any information in a consumer report.
- Attached to this Pre-Employment Screening Consent is a summary of Applicant's rights under the Federal Fair Credit Reporting Act.
- The consumer reporting agency that will provide the consumer report on Applicant is: Insert Name, address telephone number and website address of CRA.
- Applicant has a right to obtain a free copy of the consumer report. Should you desire a free copy of your consumer report, please send an e-mail to dparker@parkerlc.com requesting a copy of the consumer report and a copy will be provided to you within 3 business days of receipt of the consumer report by Parker Loss Consultants.
- To the fullest extent permitted by law, Parker Loss Consultants is authorized to provide its clients with access to all records pertaining to applicant's pre-employment screening, employment application, and post-employment screening, if any.
- Applicant is aware that: (i) Parker Loss Consultants is contractually prohibited from deploying to its clients any employee who has been convicted (including deferred adjudications) of a felony at any time and/or a misdemeanor involving dishonesty, breach of trust, intentional injury or loss to person or property, endangerment to others while under the influence of alcohol, or acts of violence (collectively a "Prohibited Offense"); (ii) Parker Loss Consultants will not employ anyone for the position(s) Applicant is seeking who fails or refuses to authorize the Company to perform and periodically update a comprehensive criminal background investigation; (iii) if employed by Parker Loss Consultants, Applicant will have an affirmative duty to disclose to Parker Loss Consultants any conviction or deferred adjudication of a Prohibited Offense which may occur while Applicant is employed by Parker Loss Consultants and that such conviction or deferred adjudication may result in an immediate termination of Applicant's employment.
- Parker Loss Consultants may in accordance with applicable law require employees to submit to random, for cause and post-accident drug and alcohol screen tests. Random testing will be administered by the company performing the testing. For cause testing may be ordered for any employee whom the Company has reason to believe has violated the Company's policies against drugs and alcohol at work and requiring employees to be sober and drug-free on the job or when otherwise required by the Company’s contractual obligations to its clients. The Company may also order any employee involved in an accident on the job to be tested, whether or not they caused the accident and/or were injured. To the fullest extent permitted by law, Parker Loss Consultants does not accommodate the use of medical or recreational marijuana and reserves the right to fire an employee who uses medical or recreational marijuana during working hours or fails a drug test due to the use of medical or recreational marijuana. Applicant hereby acknowledges and, if offered employment by Parker Loss Consultants, consents to and agrees to abide by Parker Loss Consultants's drug screening policy.
- Parker Loss Consultants and its representatives, agents and employees or designees are hereby authorized to contact the Applicant's current or any previous employer for the purpose of requesting any and all information concerning the Applicant's employment. The Applicant further authorizes all present and former employers along with personal and professional references listed in the application to give Parker Loss Consultants, its employees, agents, representatives and designees any and all information concerning the Applicant's previous employment with said employers. This information includes, but is not limited to, performance evaluations, work history and employment paperwork.
IF THE APPLICANT IS OFFERED EMPOYMENT BY PARKER LOSS CONSULTANTS, THE OFFER IS A CONDITIONAL OFFER PENDING OUTCOME OF ALL PRE-EMPLOYMENT SCREENING.
An Equal Opportunity Employer
Parker Loss Consultants bases all employment decisions, including hiring and advancement opportunities, on merit, qualifications, experience and abilities. Parker Loss Consultants complies with all applicable equal employment opportunity laws. All applicants are considered for employment without regard to race, color, national origin, religion, gender or sexual orientation, age, marital or veteran status, or disability. No question used in this application process is intended to secure information to be used for any discriminatory purpose. Parker Loss Consultants complies with the Americans with Disabilities Act and applicable state and local laws. Parker Loss Consultants does not discriminate against individuals with disabilities in hiring or employment, including job assignment, promotion, discipline, or termination. Upon request, and except where accommodations would create unreasonable hardship for Parker Loss Consultants, it is committed to making reasonable accommodations for qualified employees and applicants in accordance with applicable laws.
Digital Signature - Date and Time
