Refrigeration Valves & Systems Corp.
Employment Application

APPLICANT INFORMATION

Last Name: First: M.I.: Date:
Street Address: Apartment/Unit #:
City: State: ZIP:
Phone: Email Address:
Date Available: Social Security No.: Desired Salary:
Position Applied for:
Are you a citizen of the United States?
YES
NO
If no, are you authorized to work in the US?
YES
NO
Have You ever worked for this company?
YES
NO
If so, when
Have you ever been convicted of a felony or subjected to deferred adjudication on a felony charge?
YES
NO
If yes, explain
Referred by:
Friend
Relative
Other
Name of referral:

EDUCATION

High School:
Address:
From: To: Did you graduate? YES NO Degree:
College:
Address:
From: To: Did you graduate? YES NO Degree:
Trade/Technical:
Address:
From: To: Did you graduate? YES NO Degree:
Special Skills:

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 (Include all employment. Beginning with your current or most recent.)

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?
YES
NO
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?
YES
NO
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?
YES
NO

MILITARY SERVICE

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

DISCLAIMER AND SIGNATURE

I certify that my answers are true and complete to the best of my knowledge. I understand that any false or misleading information may result in disqualifying the applicant.

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

I hereby certify that I am submitting this form via electronic transmission in lieu of a signature.
Date:
Refrigeration Valves and
Systems Corporation
PRE-EMPLOYMENT PHYSICAL
Applicants Printed Name:
At RVS Corp. we are dedicated to maintaining a safe shop environment. It is necessary to ensure that each person beginning employment is physically able to perform required manufacturing jobs. Therefore, each applicant is required to take a pre-placement physical which includes a drug screen test. If the results are positive, you will not be offered a position at RVS, Inc.
I UNDERSTAND THAT RVS CORP. RESERVES THE RIGHT TO REQUEST A DRUG SCREEN TEST AT ANY TIME DURING MY EMPLOYMENT. I AGREE TO COMPLY WITH THIS POLICY AND A REFUSAL TO DO SO WILL RESULT IN TERMINATION.
I have read and agree to comply with the above requirements.
I hereby certify that I am submitting this form via electronic transmission in lieu of a signature.
Witness
Date
Date
P.O. Box 4649
Bryan, Texas 77805-4649
ph (979) 778-0095
Fax (979) 778-0030

Disclosure And Authorization For Consumer Reports

Disclosure

In connection with my application for employment (including contract or volunteer services) or application for tenancy with Refrigeration Valves & Systems, 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 (or contracted), this authorization shall remain on file and shall serve as ongoing authorization for Company 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 abovementioned 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: Background Screeners of America (“Agency”), 18344 Oxnard Street, Ste. 101, Tarzana, CA 91356, telephone number 866-570-4949, upon proper identification, to obtain copies of any report 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. The request includes the sources of information and the Agency, on Company’s behalf, to 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: www.wescreenusa.com

California, Minnesota and Oklahoma Residents:

I understand that if the Company is located in California, Minnesota or Oklahoma, that I have the right to request a copy of any report Company receives on me at the time the report is provided to Company. By checking the following box, I request a copy of all such reports be sent to me. Check here:

Applicant Initials

California Applicants:

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 proper 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.

New York Applicants:

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 (initial if this applies).

Washington Applicants:

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 5th Ave, Ste. 2000, Seattle, Washington 98104-3188, (206) 464-7744.

Please complete all of the fields below:

I understand that I have rights under the Fair Credit Reporting Act and I acknowledge receipt of the Summary of Rights.

Current Address:
Previous Address:
X Applicant 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.

A Summary of Your Rights Under the Fair Credit Reporting Act

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 information for free from the mortgage lender.

  • You have the right to dispute incomplete or inaccurate information.n. 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

Applicant Copy

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:

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
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 Associate Deputy Administrator for Capital Access United States Small Business Administration 406 Third Street, SW, 8th Floor Washington, DC 20416
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
Applicant Copy
Refrigeration Valves & Systems Corp.
1520 Crosswind Drive Bryan, Texas 77808 979-778-0095
Equal Employment Opportunity Form
Date:
Applicant Information
Full Name:
Last First M.I.
Address:
Address Apartment/Unit #
city State ZIP Code
Home Phone: Social Security Number:
Position Applied for:
Voluntary Information
This information is being requested in accordance with federal regulations. The information is voluntary and will not be used when considering you for employment with our company.
Racial or Ethnic Group
American Indian/Alaskan Asian/Pacific Islander Black/African American
Hispanic/Latino White/Caucasian Other
Gender
Female Male  
Military Service
Pre-Vietnam Era Vietnam Era  
Post-Vietnam Era Disabled Veteran  
How did you hear about this position?
Newspaper Company Employee Professional Publication
Job Fair Placement Office Website
Other

I hereby certify that I am a witness to to submitting this form via electronic transmission in lieu of a signature.
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