Dexios Corporation Employment Application

Applicant Information

Last Name*

First Name*

M.I.*

Street Address*

Apartment / Unit #

Postal Code*

City*

State/Region*

Today's Date*

Month/Day/Year

Phone *

Email*

Start Date*

Social Security *

Desired Salary*

Position*

Are you a citizen of the United States?*

Yes

If no, are you authorized to work in the United States?

Yes

Have you ever worked for this Company?*

Yes

If so, when?

Have you ever been convicted of a felony?*

Yes

If yes, explain.

Education

High School*

High School Address*

From:*

Month/Day/Year

To:*

Month/Day/Year

Did you graduate High School?*

Yes

Degree (High School):*

College

College Address

From (College):

Month/Day/Year

To (College):

Month/Day/Year

Did you graduate college?

Yes

Degree (College):

Other:

Other Education Address:

From (Other):

To (Other):

Did you graduate (Other)?

Yes

Degree (Other):

References

Please list three professional references:

Full Name of First Reference:*

Relationship with First Reference

Company of First Reference*

Phone Number for First Reference*

Address of Company for First Reference*

Full Name of Second Reference*

Relationship with Second Reference*

Company of Second Reference*

Phone Number for Second Reference*

Address of Company for Second Reference*

Full Name of Third Reference*

Relationship with Third Reference*

Company of Third Reference*

Phone Number for Third Reference*

Address of Company for Third Reference*

Previous Employment

1) Previous Company:

1) Previous Company Phone:

1) Previous Company Address:

1) Previous Supervisor:

1) Previous Job Title:

1) Starting Salary:

1) Ending Salary:

1) Responsibilities:

1) From:

Month/Day/Year

2) To:

Month/Day/Year

1) Reason for leaving?

1) Can we contact your previous supervisor for a reference?

Yes

2) Previous Company:

2) Previous Company Phone:

2) Previous Company Address:

2) Previous Supervisor

2) Previous Job Title

2) Previous Starting Salary:

2) Previous Ending Salary:

2) Responsibilities

2) From:

Month/Day/Year

2) To:

Month/Day/Year

2) Reason for leaving?

2) Can we contact your previous supervisor for a reference?

Yes

Military Service

Branch

From (date):

Month/Day/Year

To (date):

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

1) Electronic Signature:*

1) Today's Date:*

Month/Day/Year

DISCLOSURE/RELEASE/AUTHORIZATION FORM

By this document, Dexios Corporation discloses to you that a consumer report may be obtained for employment purposes as part of the pre-screening background check and at any time during your employment or affiliation.
This shall authorize the procurement of a consumer report by a credit reporting agency or other sources as part of the pre-screening background investigation. If accepted, this authorization shall remain on file and shall serve as an ongoing authorization for the named employer or its associates or other sources to procure consumer reports at any time during my affiliation or employment period.
I also authorize the procurement of an investigative consumer report and understand that it may contain information about my employment and educational background, criminal history, credit, workers comp claims, mode of living, character and personal reputation. I also understand you may make use of the internet including social networking sites.

I understand that I have the right to obtain additional disclosure as to the nature and scope of the investigation upon written request within a reasonable period of time and to obtain a copy of the report upon request. This authorization, in original or copy form, shall be valid for this and any future reports or updates that may be requested.
In connection with this request, I authorize all corporations, companies, former employers, supervisors, credit agencies, educational institutions, law enforcement/criminal justice agencies, city, state, county and federal courts, state motor vehicle bureaus and persons to release information they may have about me to the person or company with which this form has been filed if required, or their agent. I further authorize you to secure an investigative consumer report at any time, and any number of times, before, during and after my employment, if in the company's (or its designees) discretion, it has legally permissible and legitimate business need for the information requested.

I release and hold harmless all parties involved from any and all liability for damages arising from requesting, procuring or furnishing the requested information except with respect to a violation of the Act. I authorize the employer and it's agent/credit reporting agency and all associated entities and its clients to receive any criminal history information or credit report pertaining to me in the files of any state or local criminal justice agency.

My signature below also indicates that I have received a Summary of rights in accordance with the Fair Credit Reporting Act.

CA, MN, OK RESIDENTS ONLY: As part of a routine background investigation, we may request a consumer credit report from a consumer credit reporting agency or one of its associated companies. If we do so and you wish them to send you a free copy of this consumer credit report, please check here: .

Applicant's Signature*

Name (Printed):*

Date of Signature:*

Month/Day/Year

Other Names Used

Birth Date (MM/DD/YYYY):*

Driver's License Number:*

State:*

Current Address:*

Previous Address

Resume & Cover Letter *