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EAST TEXAS BRIDGE, INC. APPLICANT INSTRUCTIONS

Thank you for your interest in employment with our Company. We appreciate your application and look forward to the possibility of you joining our team. Please read the following instructions carefully.

Be certain that all questions are completely answered. Incomplete applications will not be considered. Note: Fields marked with a * require an answer.Use the abbreviation "N/A" if a particular provision or section in the form is not applicable to you. This application form is intended for use in evaluating your qualifications for employment. This is not a contract for employment. False or misleading information given in this form or during the interviewing process are grounds for terminating the application process or, if discovered after employment, for terminating employment. A background check and/or consumer report may be requested by the Company.

Employment decisions are made solely on the basis of qualifications to perform the work for which you are applying. Qualifications include education, training, and work experience. Credentials and experience will be verified through schools, former employers, and any other applicable sources. As an Equal Opportunity Employer, we make decisions to hire and promote without regard to race, color, age, religion, sex, national origin or ancestry, disability or physical condition, parental status, sexual orientation, gender identity, marital status, level of income, or other legally protected status.

You should understand that the position for which you are applying is considered at-will, which means that either you or the company can terminate employment for any reason or no reason at any time. No one except the company president has the authority to amend this agreement.

Our business is a subscriber to Workers' Compensation of Texas.

We appreciate your interest.

Attach Resume:	(pdf, doc, docx)
*Email:
Applying for:

Applicant Information

Education

High School:		Address:
Graduate:	Yes No	Degree:
College:		Address:
Graduate:	Yes No	Degree:
Other:		Address:
Graduate:	Yes No	Degree:
Current Certifications/Licenses Held:

Employment History

Company Name:	Complete Address (w/ City, State, Zip):
Phone:	Supervisor:
Job Title:	Responsibilities:
Starting Salary:	Ending Salary:
Start Date: (mm/dd/yyyy)	End Date: (mm/dd/yyyy)
Reason for Leaving:	May we contact your previous employer for a reference?	Yes No

Add Employer

Complete the following information only if applying for a position that requires use of a vehicle while conducting company business. If hired, your information will be verified with a Motor Vehicle Report.
How many traffic violations have you had during the last two years?
Driver's License Number:		State:

References

Name only those persons who are familiar with your work capabilities. Do not list relatives.
Name:		Phone:
Company:		Relationship:
Position:		Years Known:
Name:		Phone:
Company:		Relationship:
Position:		Years Known:
Name:		Phone:
Company:		Relationship:
Position:		Years Known:

Applicant's Statement

Notification and Agreement

I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 180 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I understand that I may be required to successfully complete a pre-employment physical examination conducted by a company-authorized physician and that I may be required to successfully pass a pre-employment drug/alcohol screening after I accept a conditional offer of employment.

DISCLOSURE TO CONSUMER

As part of our employment process, we may obtain where permitted, one or more consumer reports or investigative consumer reports about you that we obtain from a consumer reporting agency, such as:

iiX, a Verisk Analytics Business
1716 Briarcrest Drive
Suite 200
Bryan, Texas 77802

Consumer reports may include background, employment history, academic and/or professional credentials, military service, credit history, and driving history. The information gathered also may involve a criminal history and/or alcohol or drug use history, if any.
An investigative consumer report may include information about your character, general reputation, personal characteristics and mode of living that may be obtained by interviews with individuals who may have knowledge concerning any such items of information. This also may include contacts of all listed prior employers to verify your employment history.
If your employment falls under the federal Department of Transportation ("DOT") and the Federal Motor Carrier Safety Administration ("FMCSA"), including 49 CFR § 391.23, the report could include your driving, safety inspection and performance history from the FMCSA.

Under the provisions of the Fair Credit Reporting Act ("FCRA"), 15 U.S.C. § 1681 et seq.; FMCSA regulations in the Federal Code of Regulations, including 49 CFR § 40;329; and certain state laws, before we can seek such reports, where permitted, we must have your written permission to obtain the information.

You have the right, upon written request, to a complete and accurate disclosure of the nature and scope of the investigation. You also are entitled to a copy of that document entitled "Rights Under the Fair Credit Reporting Act". Under the FCRA, before we take adverse action on the basis, in whole or in part, of information in a consumer report, you will be provided a copy of that report, the name, address, and telephone number of the consumer reporting agency, and a summary of your rights under the FCRA.

Notice to California Applicants: Under California law, the reports ordered about you for employment purposes within the State of California are defined as "investigative consumer reports." These reports may contain information on your character, general reputation, personal characteristics and mode of living. Under California Civil Code § 1786.22, you may view the report(s) maintained at iiX during normal business hours. You also may obtain a copy by submitting proper identification and paying the cost of duplication by appearing at iiX in person, by mail, or by telephone. iiX is required to have personnel available to explain the report(s) and to explain any coded information. If you appear in person, you may be accompanied by a person of your choice, if s/he furnishes proper identification.
Notice to Massachusetts Applicants: Under Massachusetts law, an employer is prohibited from making written, pre-employment inquiries of an applicant about his or her criminal history. MASSACHUSETTS APPLICANTS SHOULD NOT RESPOND TO ANY OF THE QUESTIONS SEEKING CRIMINAL RECORD INFORMATION.

AUTHORIZATION TO OBTAIN INFORMATION

I have read and understood the preceding Disclosure to Consumer. Under the Fair Credit Reporting Act ("FCRA"), 15 U.S.C. § 1681 et seq., the regulations applicable to the federal Department of Transportation's Federal Motor Carriers Safety Administration, including 49 CFR § 40.329, the Americans with Disabilities Act and all other applicable federal, state, and local laws, I hereby authorize and permit the above named company to obtain information about me, where permitted, which may pertain to my employment records, driving history records, driving performance and safety history, criminal history, credit history, civil records, workers' compensation (post-offer only), alcohol and drug testing, verification of my academic and/or professional credentials, and information and/or copies of documents from any military service records.

I understand an "investigative consumer report" may include information as to my character, general reputation, personal characteristics, and mode of living that may be obtained by interviews with individuals who may have knowledge concerning any such items information. I authorize information to be obtained from my former employers to satisfy driver qualification regulations.

DOT Drivers. I understand that Title 49 of the Federal Code of Regulations, § 391.23, requires that my prospective employer and/or its agent(s) may contact employers of a driver within the last three years under the regulation of the Department of Transportation. Information such as dates of employment, position, accident history, as well as information pertaining to my drug and alcohol testing history, may be requested from each employer in accordance with Sections 391.23 and 49 CFR 40.25.

By signing below, I consent to and authorize the gathering of this information by my prospective employer or employer and those who my prospective employer has engaged to request and obtain this information including former employers, and/or from or through a consumer reporting agency, such as iiX, a Verisk Analytics Business.

I understand and acknowledge that the information provided in the consumer reports or investigative consumer reports may assist my employer or prospective employer to make a determination regarding my suitability as an employee.

I further understand that, under the FCRA, in the event of Adverse Action, I may request a copy of any consumer report from the consumer reporting agency that compiled the report, after I have provided proper identification.

I agree that a copy of this authorization has the same effect as an original. Where permitted, this authorization shall remain in effect over the course of my employment and reports may be ordered periodically during the course of my employment.

Signature below verifies you have read the above notice and understand what it means.

*First Name:		*Last Name:
MI:
*Address:		Apartment/Unit #
*City		*State
*Zip
*Phone:		Referred By:
*Have you ever worked for this company?:	Yes	No
If yes, when?:		------ To ------
How did you learn about us?	Advertisement Friend Walk-in Relative Other
If other:
Please list the names of any relatives or friends employed by East Texas Bridge, Inc.
Are you over 18 years of age?	Yes No	If you are under 18 years of age, can you provide proof of eligibility to work?	Yes No
Are you physically or otherwise unable to perform the duties of the job for which you are applying?			Yes No
If yes, please describe: (answering is voluntary and any answers will be kept confidential):
Are you currently employed:	Yes No	Are you legally authorized to work in the United States?:	Yes No
Date Available:		Salary Expected:
I can work:	Full-Time Part-Time Shift Work Temporary
Can you travel if a job requires it?	Yes No	Languages Spoken:
*Have you ever been convicted of a felony? (By company policy some misdemeanors may bar employment):	Yes	No
For purposes of employment with East Texas Bridge, Inc., "convictions" include, but are not limited to, sentenced to confinement, paid fine, time served, placed on probation (including deferred adjudication), and court-ordered restitution.
If yes, explain briefly: