Print Form - Van Ru Credit Corporation

Print Form
Still employed
COMPLETING THIS FORM IS VOLUNTARY AND
IS NOT A REQUIREMENT FOR EMPLOYMENT
INVITATION TO IDENTIFY FOR AFFIRMATIVE ACTION PURPOSES
Various agencies of the United States Government require employers to maintain information on
applicants pertaining to factors such as race, sex and type of position applied for. The information
requested on this sheet is for the purpose of our compliance with these record-keeping requirements and
Van Ru
to determine recruiting and employment patterns. _____________
believes all persons are entitled to
equal employment opportunities and does not discriminate against its employees or applicants for
employment because of race, color, sex, religion, national origin, physical or mental disability, veteran
status, age or marital status.
NAME: ___________________________________________________ DATE:
___________________
Last
First
MI
CITY/STATE OF RESIDENCE: ______________________________________________
POSITION APPLIED FOR: _________________________LOCATION: ______________
PLEASE COMPLETE THE FOLLOWING:
1. SEX/RACIAL IDENTIFICATION: Check the box that most accurately describes your sex
and racial/ethnic identity. You have the option of selecting more than one racial identification.
… Male
… Female
… White
… Black/African American
… Hispanic or Latino (All Races)
… Asian
… American Indian or Alaska Native
… Hispanic or Latino (White Race Only)
… Native Hawaiian or Other Pacific Islander
… Hispanic or Latino (All Other Races)
_________________________________________________________________________
*Race Identification: You have the option of selecting one or more racial designations.
White – A person having origins in any of the original peoples of Europe, North Africa or the
Middle East.
Black or African American – A person having origins in any of the Black racial groups of
Africa. Terms such as “Haitian” or “Negro” can be used in addition to “Black or African
American”.
Asian – A person having origins in any of the original peoples of the Far East, Southeast Asia or
the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia,
Pakistan, the Philippine Islands, Thailand, or Vietnam.
American Indian or Alaska Native – A person having origins in any of the original peoples of
North and South America (including Central America), and who maintains tribal affiliation or
community attachment.
Hispanic or Latino (All Races) – A person of Cuban, Mexican, Puerto Rican, Central or South
American, or other Spanish culture or origin, regardless of race.
Hispanic or Latino (White Race Only) – A person of Cuban, Mexican, Puerto Rican, Central
or South American, or other Spanish culture or origin, regardless of race, and of the White Race.
Hispanic or Latino (All Other Races) – A person of Cuban, Mexican, Puerto Rican, Central or
South American, or other Spanish culture or origin, and of any race other than White.
Native Hawaiian or Other Pacific Islander – A person having origins in any of the original
peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
2. How were you referred to this job:
… Advertisement
… School/College
… Employee Referral
… State Job Service
… Employment Agency
… Temporary Agency
… Government Agency
… Walk-in
… Recruiter
… Other (Please Specify): __________________________________
I have read the foregoing and it is accurate to the best of my knowledge.
Signature: _______________________________________________
RELEASE AND CONSENT TO BACKGROUND INVESTIGATION
I understand that whether I can perform work as an employee for Van Ru Credit Corporation (‘Employer”),
is conditioned on the results of certain investigative background inquiries to be made on me. These
inquiries will seek reports that will include information as to my character, work habits, work performance
and experience along with reasons for termination of past employment with previous employers. Further, I
understand that information will be requested from various federal, state, municipal and other
governmental agencies concerning my past activities relating to my driving, credit, criminal, civil and other
experiences, as well as claims involving me in the files of insurance companies including workers’
compensation. I also understand that Employer may from time to time conduct follow-up background
inquiries regarding me, including an annual background check, if hired.
I hereby authorize, without reservation, Employer to make any investigation of my personal or
employment history it deems appropriate and authorize any former employer, person, firm, corporation,
school, credit agency or government agency specifically including a criminal background check, to give
Employer any information they may have regarding me and I do hereby release and agree to hold
harmless Employer and all providers of such information regarding me from any and all liability arising
from or related to the furnishing or receipt of information about me.
This does not create a contract or agreement of employment. Employer may terminate my employment
at any time and for any reason or for no reason.
PRINT FULL NAME:
ALIASES:
SOCIAL SEC. #:
*DATE OF BIRTH:
/
/
CURRENT HOME ADDRESS:
CITY/STATE/ZIP:
COUNTIES OF RESIDENCE FOR LAST 7 YEARS: _________________
TELEPHONE NO:
DRIVER’S LICENSE NO:
STATE:
APPLICANT’S SIGNATURE:
DATE:
*Date of Birth is requested in order to correctly identify applicant when seeking to secure retrieval of
Records regarding applicant.
I understand that Employer does not discriminate in hiring or employment on the basis of race, color,
religion, sex (including pregnancy), national origin, age (40 or older), disability or genetic information.
The Employer will not use any of the information requested to discriminate against any applicant on
any of those grounds.
Classification: Confidential
Date Revised: 1/31/2011
Human Resources
VAN RU CREDIT CORPORATION
FELONY STATUS
Have you ever been convicted of a crime, had a judgment withheld or deferred, or
have you been charged with committing a crime?
"Crime" includes a misdemeanor, felony or a military offense. You may exclude
misdemeanor traffic citations.
"Convicted" includes, but is not limited to, having been found guilty by verdict of a
judge or jury, having entered a plea of guilty or nolo contendre, or having been
given probation, a suspended sentence or a fine.
YES__________
NO_____________
I understand and agree that any misinformation provided to Van Ru will irreparably harm Van
Ru, for which it will not have an adequate remedy at law.
I understand and acknowledge that by signing below I have been forthright concerning my
criminal background prior to being offered employment with Van Ru.
_____________________________
EMPLOYEE NAME (PRINT)
_____________________________
EMPLOYEE SIGNATURE
Human Resources
_________________
DATE
rev01.31.11