Application for Employment

Each question should be fully and accurately answered. No action can be taken on this application until all questions have been answered. All information given will be available only to persons who have a “need to know” or as required by law. If you need assistance in filling out this application, under the Americans with Disabilities Act (ADA), we will make reasonable accommodations. Please call 208-785-2274 or e-mail hr@ptius.net to schedule. Assistance is also available at the Idaho Department of Labor.

This application is current only for thirty (30) days, at the conclusion of which time, if you have not heard from us and still wish to be considered for employment, it will be necessary for you to fill out a new application. If an application is received with no indication as to what position you are applying for it will not be considered.

Personal Information

First Name:

Last Name:

Phone:

Street & Apt. #:

City:

State:

Zip:

Are you 18 years or older? Yes
No

Email Address:

Desired Employment

Position Applied for:

Date Available to Begin Employment:

Desired Salary:

Are you currently employed: Yes
No

If so, may we contact your current employer to inquire: Yes
No

Have you ever worked for Premier before? Yes
No

Reason for leaving:

Name of last supervisor at Premier:

Education

Do you have a High School Diploma or equivalent? Yes
No

Did you attend college? Yes
No

Additional Information

Special Training:

Professional Affiliations:

Previous Employment

List your last three employers, beginning with your most recent job first.

Employment 1

Employer Name:

Employer City:

Employer State:

Starting Date:

Leaving Date:

Job Title:

Starting Pay:

Ending Pay:

Name of Supervisor:

Supervisor Title:

Supervisor Phone:

Supervisor Email Address:

May we contact your supervisor? Yes
No

Job Description:

Reason for Leaving:

Do you want to add another employer? Yes
No

References

Please list the names of three people that you are NOT related to and that you have known for at least ONE year.

Reference 1

Name of Reference:

Phone:

Business:

Years Acquainted:

Reference 2

Name of Reference:

Email:

Phone:

Business:

Years Acquainted:

Reference 3

Name of Reference:

Email:

Phone:

Business:

Years Acquainted:

Have you been convicted of a felony within the last 5 years? If yes, please explain (this will not necessarily exclude you from consideration). Yes
No

Authorization

This Employment Application is used to notify me that the nature and scope of an investigation, if one is conducted, could include such general identification information as residence verification, and, as applicable, information concerning my employment, education, general reputation, character, personal characteristics, and habits, and that such information may be developed through personal interviews with third parties such as family members, neighbors, friends, associates, former employers, educational institutions, custodians of official records or other sources. Only job-related information developed from such a report will be considered in evaluating my employment application or continued employment. I hereby authorize these persons, companies, organizations or corporations to answer all questions or release any information regarding the items listed in this paragraph. I hereby release them form any liability and hold them, harmless from any claimfor releasing any truthful information within their knowledge and/or records.

I authorize the Company to release to any person, firm, entity or organization with which I may seek employment in the future, any truthful information within its knowledge and/or records.

I understand that any job offer that may be extended to me will be contingent upon the successful completion of a drug and alcohol test and background check.

I certify that the answers given by me to the foregoing questions and during any interview are true and correct without consequential omissions, and understand that, if employed, omissions and/or false statements on this application or during any interviews may result in dismissal. I understand and acknowledge that, if hired, my employment is for no definite period and either the Employer or I may terminate our relationship at will at any time, without notice or any reason, and that this employment application does not constitute an employment contract. I have had an opportunity to have my questions about this statement’s content and intent answered and I understand its terms.

Signature:

Date:

If you have a resume, cover letter, or other materials, feel free to upload those files here:

Attachment 1 (optional): *

Attachment 2 (optional): *

Attachment 3 (optional): *

Voluntary Self-Identification of Disability

Why are you being asked to complete this form?

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities.* To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

How do I know if I have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits major life activity, or if you have a history or record of such an impairment or medical condition.

Disabilities include, but are not limited to:

Blindness
Deafness
Cancer
Diabetes
Epilepsy
Autism
Cerebral palsy
HIV / AIDS
Schizophrenia
Muscular dystrophy

Bipolar disorder
Major depression
Multiple sclerosis (MS)
Missing limbs or partially missing limbs
Post-traumatic stress disorder (PTSD)
Obsessive compulsive disorder
Impairments requiring the use of a wheelchair
Intellectual disability (previously called mental retardation)

Yes, I have a disability (or previously had a disability)
No, I don't have a disability
I don't wish to answer

Name:

Today's Date:

Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

* Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.

Pre-Employment Background Screening Notification and Release Authorization

In connection with my application for employment (including contract or volunteer services) or application for tenancy with Premier Technology, Inc. at 1858 W. Bridge St. Blackfoot, ID 83221, I understand consumer reports will be requested by you (“Company”). These reports may include, as allowed by law, the following types of information, as applicable: names and dates of previous employers, reason for termination of employment, work experience, reasons for termination of tenancy, former landlords, education, accidents, licensure, credit, etc. I further understand that such reports may contain public record information such as, but not limited to: my driving record, judgments, bankruptcy proceedings, evictions, criminal records, etc., from federal, state, and other agencies that maintain such records.

In addition, investigative consumer reports (gathered from personal interviews, as applicable, with former employers or landlords, past or current neighbors and associates of mine, etc.) to gather information regarding my work or tenant performance, character, general reputation and personal characteristics, and mode of living (lifestyle) may be obtained.

Authorization

I hereby authorize procurement of consumer report(s) and investigative consumer report(s) by Company. If hired to procure such reports at any time during my employment, contract, or volunteer period. I authorize without reservation, any person, business or agency contacted by the consumer reporting agency to furnish the above mentioned information.

This authorization is conditioned upon the following representations of my rights:

I understand that I have the right to make a request to the consumer reporting agency below, upon proper identification, to obtain copies of any reports furnished to Company by the Agency and to request the nature and substance of all information in its files on me at the time of my request, including the sources of information, and the Agency, on Company’s behalf, will provide a complete and accurate disclosure of the nature and scope of the investigation covered by any investigative consumer report(s). The Agency will also disclose the recipients of any such reports on me which the Agency has previously furnished within the two year period for employment requests, and one year for other purposes preceding my request (California three years). I hereby consent to Company obtaining the above information from the Agency. I understand that I can dispute, at any time, any information that is inaccurate in any type of report with the Agency. I may view the Agency’s privacy policy at their website below.

As a California applicant, I understand that I have the right under Section 1786.22 of the California Civil Code to contact the Agency during reasonable hours (9:00 a.m. to 5:00 p.m. (PTZ) Monday through Friday) to obtain all information in Agency’s file for my review. I may obtain such information as follows: 1) In person at the Agency’s offices, which address is listed above. I can have someone accompany me to the Agency’s offices. Agency may require this third party to present reasonable identification. I may be required at the time of such visit to sign an authorization for the Agency to disclose to or discuss Agency’s information with this third party; 2) By certified mail, if I have previously provided identification in a written request that my file be sent to me or to a third party identified by me; 3) By telephone, if I have previously provided identification in writing to Agency; and 4) Agency has trained personnel to explain any information in my file to me and if the file contains any information that is coded, such will be explained to me.

I understand that if I am applying for employment in New York, that I have the right to receive a copy of Article 23-A of the New York Correction Law.

I understand that if the report is provided to an employer in the State of Washington, that I can contact the following office for more information regarding my rights under Washington state law in regard to these reports: State of Washington Attorney General, Consumer Protection Division, 800 5 th Ave, Ste. 2000, Seattle, Washington 98104-3188, (206) 464-7744.

Verified First / Background Screeners of America
18344 Oxnard Street, Ste. 101
Tarzana, CA 91356

(866) 570-4949
www.wescreenusa.com

Initials:

I acknowledge I have been provided a copy of consumer’s rights under the Fair Credit Reporting Act. (see below)

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA.

For more information, including information about additional rights, go to www.consumerfinance.gov/learnmore or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment – or to take another adverse action against you – must tell you, and must give you the name, address, and phone number of the agency that provided the information.
You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your “file disclosure”). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:
- a person has taken adverse action against you because of information in your credit report;
- you are the victim of identity theft and place a fraud alert in your file;
- your file contains inaccurate information as a result of fraud;
- you are on public assistance;
- you are unemployed but expect to apply for employment within 60 days.
In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.consumerfinance.gov/learnmore for additional information.
You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score informationfor free from the mortgage lender.
You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See www.consumerfinance.gov/learnmore for an explanation of dispute procedures.
Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.
Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.
Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need – usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access.
You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to www.consumerfinance.gov/learnmore.
You may limit "prescreened" offers of credit and insurance you get based on information in your credit report. Unsolicited “prescreened” offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at 1-888-567-8688.
You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.
Identity theft victims and active duty military personnel have additional rights. For more information, visit www.consumerfinance.gov/learnmore.

States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. For information about your federal rights, contact:

Business Contacts:
Type of Business:	Contact:
1.a. Banks, savings associations, and credit unions with total assets of over $10 billion and their affiliates. b. Such affiliates that are not banks, savings associations, or credit unions also should list, in addition to the Bureau:	a. Bureau of Consumer Financial Protection 1700 G Street NW Washington, DC 20006 b. Federal Trade Commission: Consumer Response Center –FCRA Washington, DC 20580 (877) 382-4357
2. To the extent not included in item 1 above: a. National banks, federal savings associations, and federal branches and federal agencies of foreign banks b. State member banks, branches and agencies of foreign banks (other than federal branches, federal agencies, and insured state branches of foreign banks), commercial lending companies owned or controlled by foreign banks, and organizations operating under section 25 or 25A of the Federal Reserve Act c. Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured state savings associations d. Federal Credit Unions	a. Office of the Comptroller of the Currency Customer Assistance Group 1301 McKinney Street, Suite 3450 Houston, TX 77010-9050 b. Federal Reserve Consumer Help Center P.O. Box 1200 Minneapolis, MN 55480 c. FDIC Consumer Response Center 1100 Walnut Street, Box #11 Kansas City, MO 64106 d. National Credit Union Administration Office of Consumer Protection (OCP) Division of Consumer Compliance and Outreach (DCCO) 1775 Duke Street Alexandria, VA 22314
3. Air carriers	Asst. General Counsel for Aviation Enforcement & Proceedings Department of Transportation 400 Seventh Street SW Washington, DC 20590
4. Creditors Subject to Surface Transportation Board	Office of Proceedings, Surface Transportation Board Department of Transportation 1925 K Street NW Washington, DC 20423
5. Creditors Subject to Packers and Stockyards Act	Nearest Packers and Stockyards Administration area supervisor
6. Small Business Investment Companies	Associate Deputy Administrator for Capital Access United States Small Business Administration 406 Third Street, SW, 8th Floor Washington, DC 20416
7. Brokers and Dealers	Securities and Exchange Commission 100 F St NE Washington, DC 20549
8. Federal Land Banks, Federal Land Bank Associations, Federal Intermediate Credit Banks, and Production Credit Associations	Farm Credit Administration 1501 Farm Credit Drive McLean, VA 22102-5090
9. Retailers, Finance Companies, and All Other Creditors Not Listed Above	FTC Regional Office for region in which the creditor operates or Federal Trade Commission: Consumer Response Center – FCRA Washington, DC 20580 (877) 382-4357

First Name:

Middle Name:

Last Name:

Social Security #:

Date of Birth:

Email:

Current Street & Apt. #:

Current City:

Current State:

Current Zip:

Previous Street & Apt. #:

Previous City:

Previous State:

Previous Zip:

Driver's License #:

State Issuing:

Other Names Used:

Signature:

Date:

Para informacion en espanol, visite www.consumerfinance.gov/learnmore o escribe a la Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

Equal Employment and Affirmative Action

It is the policy of Premier Technology, Inc. to comply with the concepts and practices of affirmative action. It is the intent of Premier and its related policies to ensure equal employment opportunity to all qualified employees.

Premier commits to provide employment opportunity to all qualified persons, and to continue to recruit, hire, train, promote, and compensate persons in all jobs without regard to race, color, religion, citizenship, gender, national origin, age, disability, current or future military status, or special disabled veteran in accordance with federal law, and without regard to any individual's status protected by applicable state or local law.

Therefore, to keep our affirmative action plan updated we request that all employees and applicants complete this form. This information is supplied voluntarily and is collected only for the exclusive use of updating our affirmative action plan and will be maintained in a confidential file.

Name:

Please indicate which of the following categories apply to you: (check all boxes that apply)

Gender

Male
Female

Ethnicity

Hispanic or Latino

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Employment Application

Application for Employment

Personal Information

Desired Employment

Education

Additional Information

Previous Employment

Employment 1

Employment 2

Employment 3

References

Reference 1

Reference 2

Reference 3

Authorization

Voluntary Self-Identification of Disability

Why are you being asked to complete this form?

How do I know if I have a disability?

Reasonable Accommodation Notice

Pre-Employment Background Screening Notification and Release Authorization

Authorization

Equal Employment and Affirmative Action

Gender

Ethnicity

Race

Veteran Status