Application For
Employment

Applicants are not required to give any information prohibited by law. It is our policy to comply with all applicable state and federal laws prohibiting discrimination in employment based on race, age, color, sex, religion, national origin, or other protected classification.

BASIC INFORMATION

ADDITIONAL INFORMATION

EDUCATION

BUSINESS OR TECHNICAL SCHOOL

HIGH SCHOOL

COLLEGE/UNIVERSITY

OTHER TRAINING / EDUCATION

DRIVERS LICENSE

WORK HISTORY

PROFESSIONAL CREDENTIALS

REFERENCES

Please provide a list of three (3) persons who are NOT RELATED TO YOU AND WHO HAVE DEFINITE KNOWLEDGE OF YOUR QUALIFICATIONS.

A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT

The federal Fair Credit Reporting Act (FCRA) is designed to promote accuracy, fairness, and privacy of information in the files of every “consumer reporting agency” (CRA). Most CRA’s are credit bureaus that gather and sell information about you — such as if you pay your bills on time or have filed bankruptcy — to creditors, employers, landlords, and other businesses. You can find the complete text of the FCRA, 15 U.S.C. 1681 — 1681u. at the Federal Trade Commission’s web site (http://www.ftc.gov). The FCRA gives you specific rights, as outlined below. You may have additional rights under state law. You may contact a state or local consumer protection agency or a state attorney general to learn those rights.

• You must be told if information in your file has been used against you. Anyone who uses information from a CRA to take action against you — such as denying an application for credit, insurance, or employment — must tell you, and give you the name, address, and phone number of the CRA that provided the consumer report.

  
  

• You can find out what is in your file. At your request, a CRA must give you the information in your file, and a list of everyone who has requested it recently. There is no charge for the report if a person has taken action against you because of information supplied by the CRA, if you request the report within 60 days of receiving notice of the action. You also are entitled to one free report every twelve months upon request if you certify that (1) you are unemployed and plan to seek employment within 60 days, (2) you are on welfare, or (3) your report is inaccurate due to fraud. Otherwise, a CRA may charge you up to eight dollars.

  
  

• You can dispute inaccurate information with the CRA. If you tell a CRA that your file contains inaccurate information, the CRA must investigate the items (usually within 30 days) by presenting to its information source all relevant evidence you submit, unless your dispute is frivolous, The source must review your evidence and report its findings to the CRA. (The source also must advise national CRA’s — to which it has provided the data — of any error.) The CRA must give you a written report of the investigation and a copy of your report if the investigation results in change. If the CRA’s investigation does not resolve the dispute, you may add a brief statement to your file, if an item is deleted or a dispute statement is filed, you may ask that anyone who has recently received your report be notified of the change.

  
  

• Inaccurate information must be corrected or deleted. A CRA must remove or correct inaccurate or unverified information from its files, usually within 30 days after you dispute it. However, the CRA is not required to remove accurate data from your file unless it is outdated (as described below) or cannot be verified. If your dispute results in any change to your report, the CRA cannot reinsert into your file a disputed item unless the information source verifies its accuracy and completeness. In addition, the CRA must give you a written notice telling you it has reinserted the item. The notice must include the name, address and phone number of the information source.

• You can dispute inaccurate items with the source of the information. If you tell anyone — such as a creditor who reports to a CR.A — that you dispute an item, they may not then report the information to a CRA without including a notice of your dispute. In addition, once you’ve notified the source of the error in writing, it may not continue to report the information if it is in fact, the error.

• Outdated information may not be reported. In most cases, a CRA may not report negative information that is more than seven years old; ten years for bankruptcies.

• Access to your file is limited. A CRA may provide information about you only to people with a need recognized by the FCR.A — usually to consider an application with a creditor, insurer, employer, landlord, or other business.

• Your consent is required for reports that are provided to employers, or reports that contain medical information. A CPA may not give out information about you to your employer, or prospective employer, without your written consent. A CRA may not report medical information about you to creditors, insurers, or employers without your permission.

• You may choose to exclude your name from CRA lists for unsolicited credit and insurance offers. Creditors and insurers may use file information as the basis for sending you unsolicited offers of credit or insurance. Such offers must include a toll-free phone number for you to call if you want your name and address removed from future lists. If you call, you must be kept off the list for two years. If you request, complete, and return CPA form provided for this purpose, you must be taken off the lists indefinitely.

• You may seek damages from violators. If a CPA, a user or (in some cases) a provider of CPA data violates the FCRA, you may sue them in state or federal court.

I certify that the facts set forth in this Application for Employment are true and complete tothe best of my knowledge. I understand that if I am employed, false statements may result indismissal. I authorize the CRSE, Inc. Home to make an investigation of any of the facts setforth in this application.

I understand that employment at the CRSE, Inc. Home is "at will," which means that eitherI or the CRSE, Inc. Home can terminate the employment relationship at any time, with or withoutprior notice, and for any reason not prohibited by statute, All employment is continued on thatbasis. I understand that no supervisor, manager or executive of the agency, other than the Boardof Directors, has any authority to alter the foregoing.