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Employment Application

THIS APPLICATION IS NOT AN EMPLOYMENT CONTRACT but merely is intended to evaluate suitability for employment. It is the policy of RK&K to provide equal employment to all qualified persons without discrimination on the basis of sex, race, color, religion, age, national origin, citizenship, disability, veteran status, or any other status protected under local, state or federal law. It is also the policy of RK&K to have the option of conducting pre-employment screening before a job offer is made. If a job offer is made, employment may be contingent upon the successful completion of a pre-employment drug screening and/or medical examination. This application will remain active for 3 years.

Personal Information
First Name:
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 Middle Name:
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 Last Name:
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Home Phone:
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 Work Phone:
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 Cell Phone:
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SSN:
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 Email Address:
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Addresses
Street: City: State: Zip Code: Since (Mo/Yr): To (Mo/Yr):
Current Address:
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Prior Address:
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Prior Address:
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Education
School Attended: City: State: Diploma: Degree/Cert.: Area of Study
High School:
Undergrad School:
Grad School:
Other School:

Fair Credit Reporting Act

Para informacion en espanol, visite www.ftc.gov/credit o escribe a la FTC Consumer Response Center, Room 130-A 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.

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 www.ftc.gov/credit or write to: Consumer Response Center, Room 130-A, Federal Trade Commission, 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.

- 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, 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 www.ftc.gov/credit 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 www.ftc.gov/credit 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 www.ftc.gov/credit.

- 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 1-888-5-OPTOUT (1-888-567-8688).

- 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 www.ftc.gov/credit.

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: CONTACT:
Consumer reporting agencies, creditors and others not listed below Federal Trade Commission:
Consumer Response Center - FCRA
Washington, DC 20580 1-877-382-4357

National banks, federal branches/agencies of foreign banks
(word "National" or initials "N.A." appear in or after bank's name)

Office of the Comptroller of the Currency
Compliance Management, Mail Stop 6-6
Washington, DC 20219 800-613-6743

Federal Reserve System member banks
(except national banks, and federal branches/agencies of foreign banks)
Federal Reserve Board
Division of Consumer & Community Affairs
Washington, DC 20551 202-452-3693

Savings associations and federally chartered savings banks
(word "Federal" or initials "F.S.B." appear in federal institution's name)
Office of Thrift Supervision
Consumer Complaints
Washington, DC 20552 800-842-6929

Federal credit unions
(words "Federal Credit Union" appear in institution's name)
National Credit Union Administration
1775 Duke Street
Alexandria, VA 22314 703-519-4600

State-chartered banks that are not members of the Federal Reserve System
Federal Deposit Insurance Corporation
Consumer Response Center, 2345 Grand Avenue, Suite 100
Kansas City, Missouri 64108-2638 1-877-275-3342

Air, surface, or rail common carriers regulated by former Civil Aeronautics Board or Interstate Commerce Commission
Department of Transportation , Office of Financial Management
Washington, DC 20590 202-366-1306

Activities subject to the Packers and Stockyards Act, 1921 Department of Agriculture
Office of Deputy Administrator - GIPSA
Washington, DC 20250 202-720-7051


Employment Consumer Report Disclosure

This disclosure is to advise you that, in the normal course of processing your employment application, we, Rummel, Klepper & Kahl, LLP (RK&K), may obtain a consumer report for employment purposes and/or an investigative consumer report for employment purposes. Property Owners’ Exchange, Inc., a consumer-reporting agency, which may play a part in our decision or may make recommendations to us regarding our decision, will provide these reports. The report provided to us by Property Owners' Exchange Inc. may include a consumer report for employment purposes from a national consumer reporting agency. That consumer reporting agency is not involved in our decision making and is unable to explain or provide information regarding our decision. The investigative consumer report provided by Property Owners' Exchange Inc. may include, but is not necessarily limited to, the following:

  • consumer report for employment purposes
  • criminal history records investigation
  • social security number validation
  • MVA driving record
  • verification of education
  • verification of employment history

Your questions regarding the reports provided by Property Owners' Exchange, Inc., may be directed to that company as follows:

Attn: Howard Levin, President
Property Owners' Exchange, Inc.
6630 Baltimore National Pike
Suite 208
Baltimore, Maryland 21228
Telephone: 410-719-0100
Toll Free: 1-800-869-3200

Employment Consumer Report Authorization

I hereby affirm that my responses on my employment application are true and correct and that I have not knowingly withheld any fact or circumstance which would, if disclosed, affect my application unfavorably.

I authorize you, Rummel, Klepper & Kahl, LLP (RK&K), to secure an investigative consumer report for employment purposes which may include, but not necessarily be limited to, a criminal history records investigation, an MVA driving record, a consumer credit report, social security number validation, verification of education and verification of employment history.

I authorize your consumer reporting agency, Property Owners' Exchange Inc., to verify any and all information contained in this application and to inquire into my character, general reputation, personal characteristics and mode of living. I release all concerned from liability in connection with any information they give. Any misrepresentation made in this application will be sufficient cause for cancellation of the application and/or for separation from the company’s service if the company employs me.

I further authorize you to secure an investigative consumer report at any time, and any number of times, before, during and after my employment, if in your discretion, you have a legally permissible and legitimate business need for the information requested.

I understand that I have the right, under Section 606(B) of the federal Fair Credit Reporting Act, to make a written request within a reasonable time for a complete and accurate disclosure of the nature and scope of the investigative consumer report.

I acknowledge receipt of the Employment Consumer Report Disclosure and the summary of consumer rights entitled,
A Summary of Your Rights Under the Fair Credit Reporting Act.

Type Name in Signature Box:

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Employment Information
Position Applied For: Date You Can Start: Desired Salary: $
Do You Prefer: Can you work:

Available:
Not Available:
Please answer all of the following questions.
1. Are you at least 18 years of age and legally eligible to work for our company in the United States?
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2. Have you worked for RK&K before?
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If yes, please provide dates and locations.
3. Have you received a description of the job or been made aware of the essential functions of the job for which you are applying?
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4. Do you understand the job requirements?
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If no, please explain.
5. Are you on layoff and subject to recall?
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6. Are you currently bound by a noncompetition, confidentiality or trade secret agreement?
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If yes, please explain...
7. Have you ever been discharged or asked to resign from a job?
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If yes, please explain...
8. Have you ever been convicted of or pled guilty to a felony or crime?
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If yes, please explain...

Employment History
May we contact your present employer?
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Please list below your last four employers beginning with the most recent:
Most Recent Employer Prior Employer (1) Prior Employer (2) Prior Employer (3)
Employer:
City:
State:
Zip Code:
Phone:
Position Held:
From (m/yyyy):
To (m/yyyy):
Pay Upon Leaving:
Supervisor:
Duties:
Reason For Leaving:

Job-related Skills
Please answer the following questions:
1. Do you have a valid driver's license?
If yes, Driver's License Number: Date of Issue:
2. Have you been convicted of or pled guilty to any traffic-related offense within the past five years?
3. Have you had your driver's license suspended or revoked or had your driving privileges modified by a court of law?
4. Please list all states from which you hold or held a driver's license:
Please use this space to list any special skills you may have that relate to the position applied for:
Please list any professional licenses, designations, certifications, etc. that may relate to the position applied for. Include date granted, name of organization, and any other relevant information.

Military Experience
Branch of U.S. Service: Active Duty Dates:
Major Duties: Service Schools Attended:

References
Reference (1) Reference (2) Reference (3) Reference (4)
Name:
Address:
Telephone:
Relationship:
Years Acquainted:

Resume (Text Version)
Copy and Paste a text version of your resume here.

Upload File
Attach a file to your application submission.

Signature

I understand that completing this application does not constitute an offer of employment and that my application may be rejected for any reason. I understand that employment with RK&K, regardless of length of service is considered “at will” and that RK&K may terminate the employment relationship at any time with or without cause. I also understand that providing false or misleading information on this form or in an interview is grounds for denial or immediate termination of employment. Finally, I understand that if I sustain any injury or illness while in the employment of RK&K, I agree that RK&K shall be entitled to receive full and complete reports and records covering any medical or related examinations and I authorize any and all such doctors, medical examiners and hospitals to give to RK&K full and complete reports and records covering such examinations, conditions, care, and treatment related to or resulting from the alleged illness or injury.

I authorize RK&K to make a complete investigation of me, including, but not limited to my past employment history, scholastic records and motor vehicle driving records. I authorize all persons and organizations to release any information concerning my background and hereby release all persons and organizations from liability for any damage whatsoever for issuing this information. I acknowledge that a telephonic facsimile (FAX) or photographic copy shall be as valid as the original.

I certify that the answers given by me to all of the questions on this application are, to the best of my knowledge and belief, true and correct without reservations. I further affirm that I have not knowingly withheld any facts or circumstances that would materially affect this application.

Under Maryland Law, an employer may not require or demand any applicant for employment or prospective employment or any employee to submit to or take a polygraph, lie detector or similar test or examination as a condition of employment or continued employment. Any employer who violates this provision is guilty of a misdemeanor and subject to a fine not to exceed $100.00. I have read and understood the above.

Type Name in Signature Box:

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