ACKNOWLEDGMENT AND AUTHORIZATION FOR CONSUMER REPORTS

In connection with your application for employment (including contract for services), with NICO Solutions, Inc., you understand that consumer reports or investigative consumer reports may be requested about you including information about your character, general reputation, personal characteristics and mode of living, employment record, education, qualifications, criminal record, driving record, credentials, and/or credit and indebtedness, and may involve personal interviews with sources such as supervisors, friends, neighbors, associates, public record or various Federal, State, or Local agencies. A consumer report containing injury and/or medical information may be obtained after a tentative offer of employment has been made.

You hereby authorize the obtaining of such consumer reports and investigative consumer reports at any time after receipt of this authorization. By signing below, you hereby authorize without reservation, any party or agency contacted by this employer, or the consumer reporting agency acting on behalf of the employer, to furnish the above mentioned information. You further authorize ongoing procurement of the above mentioned reports at any time during your continued employment or contract for services. You also agree that a fax or photocopy of this authorization with your signature shall be accepted with the same authority as the original.

For California, Minnesota or Oklahoma applicants only, if you would like to receive a copy of the consumer report,
if one is obtained, please check this box.

For California applicants only, if public record information is obtained without using a consumer reporting agency,
you will be supplied a copy of the public record information unless you check this box waiving your right to obtain a copy of the report.

* An asterisk denotes required items.

   
*Printed Name:
*Signature:
*Date:
*Social Security #:
*Date of Birth:
*Current Address:
*City *Sate *Zip
*DL #: *State:

Employment Application

Applicant Information

*Date:      
*Full Name:
*Last

*First
M.I.

   
*Address:
*Street Address
 
Apartment/Unit #
 

*City
*State
*ZIP Code
E-mail Address:    
*Desired Salary:  
*Phone:
*Date Available: *Social Security No.:
*Position Applied for:
*Are you a citizen of the United States?    
If no, are you authorized to work in the U.S.?    
If so, when?    
*Have you ever worked for this company?    
*Have you ever been convicted of a felony?
If yes, explain:

Education

High School: Address:
From: To: Did you graduate? Degree:
College: Address:
From: To: Did you graduate? Degree:
Other: Address:
From: To: Did you graduate? Degree:

References

Please list three professional references.

*Full Name: *Relationship:
*Company: *Phone:
*Address:
Full Name: Relationship:
Company: Phone:
Address:
Full Name: Relationship:
Company: Phone:
Address:

Previous Employment

*Company: *Phone:
*Address: *Supervisor:
*Job Title: *Starting Salary: *Ending Salary:
*Responsibilities:
*From: *To: *Reason for Leaving:
*May we contact your previous supervisor for a reference?
Company: Phone:
Address: Supervisor:
Job Title: Starting Salary: Ending Salary:
Responsibilities:
From: To: Reason for Leaving:
May we contact your previous supervisor for a reference?
Company: Phone:
Address: Supervisor:
Job Title: Starting Salary: Ending Salary:
Responsibilities:
From: To: Reason for Leaving:
May we contact your previous supervisor for a reference?

Military Service

Branch: From: To:
Rank at Discharge: Type of Discharge:
If other than honorable, explain:

Disclaimer and Signature

By entering the text in the box below I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Signature: Date: