PROFESSIONAL REFERENCESList below three persons not related <strong>to</strong> you who have knowledge of your work performance within the last threeyears.First Name Last Name Telephone No.Address & Street City State ZipOccupationNo. of Years AcquaintedFirst Name Last Name Telephone No.Address & Street City State ZipOccupationNo. of Years AcquaintedFirst Name Last Name Telephone No.Address & Street City State ZipOccupationNo. of Years AcquaintedPLEASE READ CAREFULLY AND SIGN BELOWI hereby certify that I have not knowingly withheld any information that might adversely affect mychances for employment <strong>and</strong> that the answers given by me are true <strong>and</strong> correct <strong>to</strong> the best of myknowledge. I further certify that I, the undersigned applicant, have personally completed thisapplication. I underst<strong>and</strong> that any omission or misstatement of material fact on this applicationor on any document used <strong>to</strong> secure employment shall be grounds for rejection of this application or forimmediate discharge if I am employed, regardless of the time elapsed before discovery.I hereby authorize Whistles<strong>to</strong>p <strong>to</strong> thoroughly investigate my references, work record,education <strong>and</strong> other matters related <strong>to</strong> my suitability for employment <strong>and</strong>, further, authorize the referencesI have listed <strong>to</strong> disclose <strong>to</strong> the agency any <strong>and</strong> all letters, reports <strong>and</strong> other information related <strong>to</strong> my workrecords, without giving me prior notice of such disclosure. In addition, I hereby release theagency, my former employers <strong>and</strong> all other persons, corporations, partnerships <strong>and</strong> associationsfrom any <strong>and</strong> all claims, dem<strong>and</strong>s or liabilities arising out of or in any way related <strong>to</strong> suchinvestigation or disclosure.I underst<strong>and</strong> that nothing contained in the, or conveyed during any interview which maybe granted or during my employment, if hired, is intended <strong>to</strong> create an employment contract betweenme <strong>and</strong> the agency. In addition, I underst<strong>and</strong> <strong>and</strong> agree that if I am employed, my employment is (At-will)for no definite or determinable period <strong>and</strong> may be terminated at any time, with or without priornotice, at the option of either myself or the agency, <strong>and</strong> that no promises or representationscontrary <strong>to</strong> the foregoing are binding on the agency unless made in writing <strong>and</strong> signed by me <strong>and</strong>the agency’s designated representative.Upon employment, you will be required <strong>to</strong> submit <strong>to</strong> a finger print criminal record background check<strong>and</strong> may be required again in three years. Conviction of certain sexual felonies will disqualify you forcontinued employment with Whistles<strong>to</strong>p.I, the undersigned, have read <strong>and</strong> underst<strong>and</strong> the above requirements.DateApplicant’s Signature5
DISCLOSUREDISCLOSURE - Must be a clear <strong>and</strong> conspicuous written disclosure <strong>to</strong> the consumerbefore the report is obtained, in a document that consists solely of the disclosure. Samplelanguage is shown below:As part of our hiring background <strong>and</strong> investigation, we may obtain consumer reports or preparean investigative consumer report. The investigative consumer report may consist of contactingall listed prior employers <strong>to</strong> verify your employment his<strong>to</strong>ry. It may also include, but not belimited <strong>to</strong>, credit information reports, criminal his<strong>to</strong>ry reports <strong>and</strong> driving his<strong>to</strong>ry records. Underthe provisions of the Fair Credit Reporting Act (15 USC at 1681-1681u) as amended, before wecan seek such reports, we must have your written permission <strong>to</strong> obtain the information. You havethe right, upon written request, <strong>to</strong> a complete <strong>and</strong> accurate disclosure of the nature <strong>and</strong> scope ofthe investigation. You are also entitled <strong>to</strong> a copy of your Rights Under the Fair Credit ReportingAct.
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