Danville Services Corporation - Online Employment Application

Online Pre-Employment Questionnaire
An Equal-Opportunity Employer

All fields need to be completed or the form will not transmit.

Date: 09/05/2010
Personal Information:

Name:	Last: First: Middle:
E-mail Address:
Present Address:
Permanent Address:
Phone Number:
Are you 18 years or older?
Are you either a U.S. citizen or an alien authorized to work in the United States?
How did you hear about the position?

What days and hours are you available to work?
Desired Position:
Date you can start:
Salary Desired:
Are you employed now?
Have you ever been employed by this company?
Do you have any relative currently working at Danville
If so ...	NameRelationship
If yes, when and where?

Former Employers
List below your last 3 employers, starting with the most recent.

Date (Mon. / Yr.)	Name, Address & Phone of Former Employer	Salary	Position	Reason for Leaving

References
List the names of three persons, not related to you, whom you have known at least one year.

Name	Address & Phone:	Business	Years Acquainted

Have you ever been convicted of a felony?
Is there a possibilty your name may appear on the abuse register?
If yes to either or both, please explain:
In case of emergency, please notify:	Name: Address: Phone #:

"I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND UNDERSTAND THAT IF EMPLOYED FALSIFIED STATEMENTS ON THIS APPLICATION WILL BE GROUNDS FOR DISMISSAL. I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES LISTED ABOVE,TO GIVE DANVILLE SERVICES OF ARIZONA, LLC (DANVILLE) ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT, AND ANY PERTINENT INFORMATION THEY MAY HAVE, PERSONAL OR OTHERWISE, AND RELEASE ALL PARTIES FROM ALL LIABILITY FOR ANY DAMAGE THAT MY RESULT FROM FURNISHING SAME TO DANVILLE. DANVILLE IS AN AT-WILL EMPLOYER, WHICH MEANS THAT EMPLOYMENT WITH DANVILLE IS FOR AN UNSPECIFIC DURATION, AND THAT THIS EMPLOYMENT RELATIONSHIP MAY BE TERMINATED AT ANY TIME, FOR ANY REASON OR NO REASON, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, EITHER BY THE EMPLOYEE OR BY DANVILLE. "
I agree to the above statement.

ATTACHMENT TO APPLICATION The Immigration Reform and Control Act (IRCA) of 1986 requires that all new employees provide verification of US citizenship, or that they possess INS authorization, to work in the United States. You will be asked to complete Section I of the I-9 on your first day of employment, and will be required to present the appropriate documents no later than your third day of employment. If we have not received your proper support documentation that verifies you are legal to work in the United States within 3 days of employment, you may be terminated. Danville Services of Arizona also confirms eligibility to work in the U.S. through E-Verify, an on-line government verification system. I agree to allow the Arizona Dept. of Human Services (DHS) Licensing to request background verification with the Department of Social Services and Adult and Child Abuse Register and to obtain a BCI check upon hire and annually. I understand that if I am hired and approval is denied by DHS licensing, my employment will be terminated. Danville Services of Arizona, LLC (Danville) also reserves the right to determine whether or not I will be allowed to drive company vehicles, or transport clients in my own vehicle, based on a check of my driving record and providing a proof of insurance. A record containing a DUI/DWI, driving on a suspended license, three or more moving violations, or violations which Danville determines are serious enough that I am not approved to drive, will prevent approval for a driving position, which may jeopardize my employment with Danville. Additionally, to drive company vehicles, or transport clients in my personal vehicle, I must be 21 years of age, if I have moved from another state, meet the specific state guidelines for obtaining an Arizona driver’s license, and my vehicle must meet all state safety requirements. The release of any and all information is authorized whether same is of record or not and I do hereby release all persons, firms, agencies, companies, groups or installations whomsoever, from any damages of, or resulting from furnishing such information to Danville and the Insurance Company. If hired, I accept employment understanding the above conditions. Below I have listed my current address and phone number.
I agree to the above statement.
APPLICANT: Please complete boxed section only and return with application. Danville will complete the reference check process REQUEST FOR EMPLOYMENT INFORMATION COMPLETE ALL FIELDS –ASK THE ADMINISTRATIVE ASSISTANT FOR A PHONE BOOK IF NECESSARY
Last Four Digits of SSN
Name
Company you worked for:
Supervisor’s Name:
Company Address:
Company Telephone:
Dates of Employment:
Position:
Having made application with Danville Services of NV, LLC, I hereby authorize the release of information directly to said Company. I release and hold harmless present and past employers, references and all persons and institutions whomsoever, from any charge because of furnishing information. I waive any application to the Family Education and Privacy Act insofar as the same might apply to responding to this request for information.
I agree to the above statement.

Danville Services Corporation 7351 S Union Park Ave Suite 200 Midvale, UT 84047 Phone:(801)565-0700 Toll Free (888)417-0711