Danville Services of Oregon LLC - Online Pre-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:
Message Number:
Most of the positions here require the ability to lift 50 lbs. Can you, without any restrictions, perform this job duty?
Are you 18 years or older?
Are you 21 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?
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?
Have you ever been alleged to have abused, neglected, or abandoned a child or adult where the allegations were substantiated?
If yes to either or both, please explain:
Do you have a current and valid driver’s license?
Have you had three or more moving violations, a DUI, a suspension, or a revocation in the past five years?
If yes, please explain:
In case of emergency, please notify:	Name: Address: Phone #:
How did you hear about the job position?

"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 shall be grounds for dismissal. I authorize investigation of all statements contained herein and the reference and former employers listed above to give you 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 may result from furnishing the same to you. I understand and agree that, if hired, my employment with Danville Services of Oregon, LLC, can be terminated with or without cause, and with or without prior notice, at any time, at the option of Danville Services of Oregon, LLC, or at my option. I also understand and agree that Danville Services of Oregon, LLC, reserves the right to change, add to, or delete employment-related policies and procedures at any time. Changes in employment-related policies and/or procedures will be effective on dates determined by the company. I understand that I may not rely on policies or procedures that have been superseded. I also understand that no supervisor or manager other than the CEO has the authority to alter the policies and those such changes must be in writing. "
I agree to the above statement.

EMPLOYEE STATEMENT PERTAINING TO BACKGROUND INVESTIGATION MY SIGNATURE BELOW INDICATES THAT I HAVE NOT BEEN CONVICTED OF ANY OF THE FOLLOWING CRIMES OR CIVIL OFFENSES: Murder or voluntary manslaughter. Assault of any kind. Sexual assault, statutory sexual seduction, incest, lewdness, indecent exposure, or any other sexually-related crime. Abuse, neglect or abandonment of child or adult or contributing to the delinquency of a minor. Violation of any federal or state law concerning the possession, distribution or any use of any controlled substance or any dangerous drug within the past seven years. Any offense involving fraud, theft, embezzlement, burglary, robbery, fraudulent conversion or misappropriation of property within the past seven years. Any other felony involving the use of a firearm or other deadly weapon within the immediately preceding seven years. By signing below, I agree to allow Danville Services of Oregon, L.L.C. and/or the Oregon Dept. of Human Services to obtain my fingerprints and to request background verification. I also agree to allow Danville and/or the Oregon Department of Human Services to obtain a Background Criminal History check. Should any disqualifying conviction or substantiated abuse, neglect, or abandonment finding arise through this background check, I understand that I will no longer be qualified for employment with Danville and any employment relationship I have established with Danville will be terminated. I understand that in order to work in a position that requires driving company vehicles or my vehicle for business purposes, I must have a driving record with no more than three moving violations/minor offenses and no DUI, suspensions, or license revocations in the past five years I understand that failure to meet the driving requirements could jeopardize my position with Danville Services of Oregon, L.L.C. The release of any and all information is authorized whether the 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/or Danville’s Insurance Companies.
I agree to the above statement.
Request for Employment Verification Having made application with Danville Services of Oregon, L.L.C., 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 this request for information
Last Four Digits of SSN
Name
I agree to the above statement.

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