Green Valley Cooling & Heating
645 W. Ward Lane
GREEN VALLEY, AZ 85614
(520) 625-1234
Pre-employment Screening Application
Personal Information Help
Legal Name     
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**House/P.O. Number:   
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**State:
**DOB:
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**(denotes required field)   Please make sure to complete all tabs shown below before submitting your background application.
Desired salary?
**********Answer Required**********


Date you're available to start?
**********Answer Required**********


What position are you applying for?
**********Answer Required**********


Are you a citizen of the United States? Yes or No. If no, are you authorized to work in the U.S.? Yes or No.
**********Answer Required**********


Have you ever worked for this company? Yes or No. If yes, when?
**********Answer Required**********


Have you ever been convicted of a felony? Yes or No. If yes, explain.
**********Answer Required**********


Military Service (Includes Branch, Dates, Rank at discharge, Type of Discharge, If other than honorable, explain).
**********Answer Required**********


Initial in the box below if you agree that, The information that I have provided on this application is accurate to the best of my knowledge and may be verified by Green Valley Cooling & Heating or its agents.
**********Answer Required**********


Initial in the box below if you agree that, I authorize all the schools, persons and organizations named in this application to provide any relevant information in their possession or knowledge to the agents of Green Valley Cooling & Heating, for use in deciding whether or not to offer me employment and specifically waive any required written notification. I hereby release Green Valley Cooling & Heating, my former employers and all other persons from any and all claims, demands, or liabilities arising out of or in any way related to such inquiry or disclosure.
**********Answer Required**********


Initial in the box below if you agree that, I understand that Green Valley Cooling & Heating is committed to maintaining a drug and alcohol free work place. Accordingly, I may be subject to a pre-employment blood test, urinalysis or other drug/alcohol screening. I further understand that if employed, I may be subject to such a drug and alcohol screening if the Green Valley Cooling & Heating has reasonable suspicion to believe that I am under the influence of a drug or alcohol. Green Valley Cooling & Heating also conducts random drug and alcohol screenings throughout the year and I may or may not be chosen for a screening. My consent to submit to such a test is required as a condition of employment and my refusal to consent shall result in a refusal to hire or, if already employed, termination.
**********Answer Required**********


Initial in the box below if you agree that, I understand and agree that any misrepresentation or omission of facts in this application will be justification for refusal or termination of employment, regardless of the time elapsed before discovery.
**********Answer Required**********


Initial in the box below if you agree that, I understand and agree that the employment for which I am applying for is at-will and such employment may be terminated at any time with or without cause, without prior notice, by either myself or Green Valley Cooling & Heating. There will be no agreement, express or implied between Green Valley Cooling & Heating and me for any specific period of employment, nor for continuing or long term employment, unless made in writing, signed by an authorized representative of Green Valley Cooling & Heating.
**********Answer Required**********


Initial in the box below if you agree that, I have placed my signature in the space provided below only after I have completed the entire application to the best of my ability and have carefully read the statements above.
**********Answer Required**********


List any additional previous addresses (at least City and State) where you have lived in the past 7 years.


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List all previous employers, where you have worked in the last 7 years. Please make sure to include phone numbers and/or email information.
When you place a check mark in the box this notifies us that we can contact your former employer.









Employer Name

Employed From (MM/YYYY) Employed To (MM/YYYY)

Street Address Zipcode City State

Occupation/Position Supervisor Contact Name

Phone Extension Fax
Employer Name

Employed From (MM/YYYY) Employed To (MM/YYYY)

Street Address Zipcode City State

Occupation/Position Supervisor Contact Name

Phone Extension Fax
Employer Name

Employed From (MM/YYYY) Employed To (MM/YYYY)

Street Address Zipcode City State

Occupation/Position Supervisor Contact Name

Phone Extension Fax
List the most recent level of education completed and any other education you wish to be considered.








School Type School Name

Street Address

Zip Code City State

Phone Fax Date Completed (MM/YYYY)

Years Attended Graduated Enrolled From (MM/YYYY) Enrolled To (MM/YYYY)

Major Degree Name Graduated Under


School Type School Name

Street Address

Zip Code City State

Phone Fax Date Completed (MM/YYYY)

Years Attended Graduated Enrolled From (MM/YYYY) Enrolled To (MM/YYYY)

Major Degree Name Graduated Under


List any references that we may contact to verify information included in this application. No friends or relatives.

Name Relationship Years Known

Street Address Zip Code City State

Home Business Other

E-Mail Address


Name Relationship Years Known

Street Address Zip Code City State

Home Business Other

E-Mail Address


Name Relationship Years Known

Street Address Zip Code City State

Home Business Other

E-Mail Address



You must read and agree to the below release authorization.



   
FAIR CREDIT REPORTING ACT DISCLOSURE AND AUTHORIZATION TO CONDUCT BACKGROUND INVESTIGATION

PLEASE REVIEW CAREFULLY BEFORE SIGNING THE BELOW AUTHORIZATION

Green Valley Cooling & Heating (“the Company”) may obtain information about you for employment purposes from a third-party consumer reporting agency. Thus, by signing below, you agree that you may be the subject of a “consumer report” which may contain information regarding your credit history, criminal history, social security verification, motor vehicle and driving records, verification of your education or employment history or other background checks. Credit history may be requested if such information is relevant to the duties and responsibilities of the position for which you are applying. The scope of this notice and authorization allows the Company to obtain from any outside organization all manner of consumer reports now and throughout the course of your employment to the full extent permitted by law. I understand that this release authorization will remain in effect for the duration of my employment unless I revoke this authorization in writing.

ACKNOWLEDGMENT AND AUTHORIZATION

I acknowledge receipt of this FCRA DISCLOSURE AND AUTHORIZATION TO CONDUCT BACKGROUND INVESTIGATION and certify that I have read and understand it. I hereby authorize the obtaining of “consumer reports” by the 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, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by an outside organization acting on behalf of the Company, and/or the Company itself. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.

California applicants or employees only: By signing below, you also acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW. You may have the right to receive a copy of an investigative consumer report or consumer credit report at no charge if one is obtained by the Company whenever you have a right to receive such a copy under California law.


Minnesota applicants or employees only: By signing below you also acknowledge that you understand that you have the right to make a request in writing to the consumer reporting agency of the nature and scope of the report, if any, and the agency is obligated to respond to your request within five days of your request for further information or of your request for the report, whichever is later.

Oklahoma applicants or employees only: You have the right to request a copy of a consumer report at no charge if one is obtained by the Company.


NOTICE REGARDING BACKGROUND INVESTIGATION

PURSUANT TO CALIFORNIA LAW




Green Valley Cooling & Heating (“the Company”) intends to obtain information about you for employment screening purposes from a consumer reporting agency. Thus, you can expect to be the subject of “investigative consumer reports” and “consumer credit reports” obtained for employment purposes. Such reports may include information about your character, general reputation, personal characteristics and mode of living. With respect to any investigative consumer report from an investigative consumer reporting agency (“ICRA”), the Company may investigate the information contained in your employment application and other background information about you, including but not limited to the following: obtaining a criminal record report and verifying references, work history, your social security number, your educational achievements, licensure and certifications, your driving record, and other information about you. The results of this report may be used as a factor in making employment decisions. The source of any investigative consumer report (as that term is defined under California law) will be Securitech, Inc., 8230 E. Broadway Blvd., Suite E-10, Tucson, AZ 85710 or (520) 721-0305 or (800) 805-4473. A copy of Securitech’s privacy policies is available online at www.localscreening.com. The Company agrees to provide you with a copy of an investigative consumer report when required to do so under California law.

Under California Civil Code § 1786.22, you are entitled to find out from an ICRA what is in the ICRA’s file on you with proper identification, as follows:
• In person, by visual inspection of your file during normal business hours and on reasonable notice. You also may request a copy of the information in person. The ICRA may not charge you more than the actual copying costs for providing you with a copy of your file.
• A summary of all information contained in the ICRA’s file on you that is required to be provided by the California Civil Code will be provided to you via telephone, if you have made a written request, with proper identification, for telephone disclosure, and the toll charge, if any, for the telephone call is prepaid by or charged directly to you.
• By requesting that a copy be sent to a specified addressee by certified mail. ICRAs complying with requests for certified mailings shall not be liable for disclosures to third parties caused by mishandling of mail after such mailings leave the ICRAs.

“Proper Identification” includes documents such as a valid driver’s license, social security account number, military identification card, and credit cards. Only if you cannot identify yourself with such information may the ICRA require additional information concerning your employment and personal or family history in order to verify your identity.

The ICRA will provide trained personnel to explain any information furnished to you and will provide a written explanation of any coded information contained in files maintained on you. This written explanation will be provided whenever a file is provided to you for visual inspection.

You may be accompanied by one other person of your choosing, who must furnish reasonable identification. An ICRA may require you to furnish a written statement granting permission to the ICRA to discuss your file in such person’s presence.






Enter any names by which you have been known and the dates those names were used.

First Last From (MM/YYYY) To (MM/YYYY)
List any professional credentials/licensures you possess. License Type  License #

Description

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Description

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Zip Code City State

Phone Extension Fax

License Type  License #

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License Type  License #

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Phone Extension Fax




Green Valley Cooling & Heating provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability, veteran status, or genetics. In addition to federal law requirements, Green Valley Cooling & Heating complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.