Background Screen Drug Screen Motor Vehicle Report (if applicable)

Transcripción

1 In order to attract and retain the best possible applicants, Select Energy Services requires, at minimum, the following items from applicants if they are to be considered for hire: Background Screen Drug Screen Motor Vehicle Report (if applicable) Thank you for your patience and understanding through our process. We believe our pre-screening process provides the best possible environment for our customers and employees.

2 In compliance with Federal and State equal employment opportunity laws, Select Energy Services, LLC is an Affirmative Action/Equal Opportunity Employer and does not discriminate in regard to race, color, national origin, religion, disability, age, or gender. Date of Application: Location applied for: Position applied for: Business Unit applied for: PERSONAL INFORMATION Name: Last First MI SSN#: Home #: Cell #: DL #: State: Class: List your address of residency for the past 3 years. Current Address: Previous Address: Street City/State/Zip How long? Street City/State/Zip How long? Do you have the legal right to work in the United States? Are you at least 18 years old? Have you ever been convicted of a crime or placed on deferred adjudication? If yes, please explain* *This does not automatically disqualify you for employment. Who referred you? Rate of pay expected: Are you able to perform the essential functions of the job(s) for which you are applying with or without reasonable accommodation? Have you worked for any of our companies before? Where? From: To: Rate of Pay: Position: Reason for leaving: Are you currently employed? May we contact your CURRENT employer? Application for Employment Page 2 of 10 Updated

3 EMPLOYMENT HISTORY Application for Employment Please note any gaps in employment. List past 3 years of employment history. Begin with current or most recent employment and work in reverse. You may use the back of this sheet for additional employment information that may be related to the position you are applying for. 1. Company: From: To: Address: Position: City: State/Zip: Salary/Wage: Supervisor/Contact Person: Phone #: Brief description of job duties: Were you terminated? Reason for Leaving or Termination: 2. Company: From: To: Address: Position: City: State/Zip: Salary/Wage: Supervisor/Contact Person: Phone #: Brief description of job duties: Were you terminated? Reason for Leaving or Termination: 3. Company: From: To: Address: Position: City: State/Zip: Salary/Wage: Supervisor/Contact Person: Phone #: Brief description of job duties: Were you terminated? Reason for Leaving or Termination: Application for Employment Page 3 of 10 Updated

4 EDUCATION Circle highest grade completed: High School College Last School Attended: Name City/State Please list any degrees/certifications: REFERENCES (Please list at least 2 employment references) Name: Phone: Years Known: How Acquainted? Name: Phone: Years Known: How Acquainted? Name: Phone: Years Known: How Acquainted? STATEMENT OF CERTIFICATION I hereby certify that the foregoing statements are true and correct to the best of my knowledge and belief, and hereby grant Select Energy Services, LLC permission to verify such answers. I understand that any false statement on this application may be considered as sufficient cause for rejection of this application, or dismissal if such false statement on this application is discovered subsequent to my employment. I understand that employment at this company is "at will," which means that either I or this company can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statute. Prior to being hired, all applicants accepted for employment with Select Energy Services, LLC will provide positive proof of identification and proof of eligibility to work in the United States and complete a pre-employment drug test. In accordance with the provisions of Section 604 (b) (2) (A) of the Fair Credit Reporting Act, Public Law , as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter I, of Public Law ), you are being informed that reports verifying your previous employment, previous drug and alcohol tests results, and your driving record may be obtained on you for employment purposes. These reports are required by Section 382, 413, , and of the Federal Motor Carrier Safety Regulations. Printed Name Applicant Signature Date Application for Employment Page 4 of 10 Updated

5 FCRA AUTHORIZATION Application for Employment Notification and Authorization for Consumer Reports and Investigative Consumer Reports Pursuant to the Fair Credit Reporting Act, Title VI [15USC 16811] This document shall serve as notification to you that Select Energy Services and/or any of its subsidiaries (hereinafter collectively referred to as "Company") may request a consumer report for the purpose of evaluating you for employment. This authorization may also be used at a later date to obtain a consumer report or an investigative consumer report for purposes including, but not limited to, your promotion, reassignment, or retention as an employee. This authorization shall remain on file and will serve as ongoing authorization for Company to request consumer reports and/or investigative consumer reports at any time during your employment period. This release and authorization acknowledges that you understand that Company may now, or at any time during your employment, conduct verifications of, including but not limited to, your education, previous employment, credit history, driving record, military records, any public records, social security number, and previous and current addresses. Additionally, this notification is authorization to contact personal references, obtain screening for the presence of drugs or alcohol, and obtain criminal history information pertaining to you which may be maintained by Federal, State, County, or Local criminal justice agencies, court houses, or criminal record repositories. This notification and release are made pursuant to the provisions of the Fair Credit Reporting Act, Title VI [15 USC 1681]. If any adverse action is contemplated b as e d on any information contained in the consumer report or investigative consumer report, Company will, prior to any action being taken, provide to you the report along with a copy of your rights under this Act. I have read and understand this consent and hereby authorize Company to obtain consumer reports and/or investigative consumer reports regarding my employment. Applicant Signature Printed Name Date DOB SSN State/License# Application for Employment Page 5 of 10 Updated

6 AUTORIZACIÓN DE LA FCRA Notificación y autorización para informes del consumidor e informes de investigación del consumidor conforme a la Ley de Informes Crediticios Justos, Título VI [15USC 1681] El presente documento servirá para notificarle de que Select Energy Services o cualquiera de sus subsidiarias (en adelante denominadas en forma conjunta la Compañía ) pueden solicitar un informe del consumidor con el fin de evaluarlo para el empleo. Esta autorización también puede utilizarse en una fecha posterior para obtener un informe del consumidor o un informe de investigación del consumidor con fines de, por ejemplo, ascenso, reasignación o retención como empleado. Esta autorización permanecerá en su expediente y servirá como una autorización permanente para que la Compañía solicite informes del consumidor o informes de investigación del consumidor en cualquier momento durante su período de empleo. A través de esta exención y autorización, usted reconoce que comprende que la Compañía puede ahora, o en cualquier momento durante su empleo, llevar a cabo verificaciones que incluyen, por ejemplo, su educación, empleo anterior, antecedentes crediticios, registro de conducción, registros militares, registros públicos, número de seguro social y direcciones anteriores y actual. Asimismo, esta notificación es una autorización para comunicarse con referencias personales, obtener un examen para detectar la presencia de drogas o alcohol y obtener información de antecedentes penales relacionados con usted que pueden mantener agencias federales, estatales o locales de justicia penal, juzgados o repositorios de antecedentes penales. Esta notificación y exención se realizan de acuerdo con las disposiciones de la Ley de Informes Crediticios Justos (FCRA, por sus siglas en inglés), Título VI [15 USC 1681]. Si se contempla alguna acción adversa basada en información incluida en el informe del consumidor o informe de investigación del consumidor la Compañía, antes de tomar cualquier medida, le proporcionará el informe junto con una copia de sus derechos conforme a esta Ley. He leído y entiendo este consentimiento y por lo tanto autorizo a la Compañía a obtener informes del consumidor o informes de investigación del consumidor con respecto a mi empleo. FIRME AQUÍ EN LETRA DE IMPRENTA AQUÍ FECHA Application for Employment Page 6 of 10 Updated

7 BACKGROUND INFORMATON DATA SHEET FOR PURPOSES OF BACKGROUND INVESTIGATION ONLY Name: (Last) (First) (Middle) SSN: *Maiden/Other Names Used: Phone: Driver s License/State ID: State: Date of Birth: Male: Female: RESIDENCES for the Last Seven (7) Years: List present address first. Address: / Street Apt. No. City State Zip From / To Address: / Street Apt. No. City State Zip From / To Address: / Street Apt. No. City State Zip From / To EMPLOYMENT for the Last Seven (7) Years: Start with current or most recent. May We Contact Current Employer? Yes No Employer: Job Title: From: (Month/Year) / To: / Supervisor/Title: City State Zip Phone Employer: Job Title: From: (Month/Year) / To: / Supervisor/Title: City State Zip Phone Employer: Job Title: From: (Month/Year) / To: / City State Zip Phone Supervisor/Title: EDUCATION: High School: From: To: Graduated Did Not Graduate GED* Diploma City State Zip *Location GED was obtained: College: From: To: Graduated Did Not Graduate Degree/State Degree: City State Zip Month/Year Degree Received: College: From: To: Graduated Did Not Graduate Degree/State Degree: City State Zip Month/Year Degree Received: ACKNOWLEDGEMENT: I understand that this form will not be retained with any permanent personnel file, and that the sole purpose of this document is to facilitate a background investigation. I further understand that the information I have provided herein will NOT be considered in any hiring decision, except for reasons of falsification. By my signature below, I acknowledge my understanding of these facts, and further attest that all of the information I have provided is true and correct. I hereby authorize all persons, schools, all former employers, organizations, law enforcement agencies, or any other entity having information on me, to provide, either verbally or in writing, to, Select Energy Services its agents, or assignees, all pertinent background information that has been deemed necessary for Select Energy Services to arrive at an employment decision. Furthermore, I agree to hold Select Energy Services, its agents, assignees, and any other person or entity that releases the aforementioned information, harmless and agree to release them from any liability arising from said background investigation. A photocopy or facsimile of this original form will serve as authorization. Signature: Date: Application for Employment Page 7 of 10 Updated

8 HOJA DE DATOS DE INFORMACIÓN DE ANTECEDENTES SÓLO CON FINES DE INVESTIGACIÓN DE ANTECEDENTES Nombre: (Apellido) (Nombre) (Segundo nombre) *Nombre de soltera/ Otros nombres utilizados: Número de seguro social: Número de teléfono: Application for Employment Licencia de conductor o ID del estado: Estado: Fecha de nacimiento: Hombre Mujer RESIDENCIAS en los últimos siete (7) años: Indique la dirección actual primero. Dirección: / Calle Nº Apt. Ciudad Estado Código postal Desde / Hasta Dirección: / Calle Nº Apt. Ciudad Estado Código postal Desde / Hasta Dirección: / Calle Nº Apt. Ciudad Estado Código postal Desde / Hasta EMPLEO en los últimos siete (7) años: Comience con el actual o más reciente. Podemos comunicarnos con su empleador actual? Sí No Empleador: Cargo del candidato: Desde: (Mes/Año) / Hasta: / Supervisor: Cuidad Estado Código postal Teléfono Empleador: Cargo del candidato: Desde: (Mes/Año) / Hasta: / Cuidad Estado Código postal Teléfono Supervisor: Empleador: Cargo del candidato: Desde: (Mes/Año) / Hasta: / Cuidad Estado Código postal Teléfono Supervisor: EDUCACIÓN: Escuela secundaria: Desde: Hasta: Se graduó No se graduó GED* Diploma Ciudad Estado Código postal *Lugar donde obtuvo el GED: Universidad: Desde: Hasta: Se graduó No se graduó Título/ Título estatal : Ciudad Estado Código postal Mes/Año en que recibió el título: Universidad: Desde: Hasta: Se graduó No se graduó Título/ Título estatal : Ciudad Estado Código postal Mes/Año en que recibió el título: ACEPTACIÓN Entiendo que este formulario no puede ser conservarse con ningún expediente de personal permanente y que el único objetivo de este documento es facilitar una investigación de antecedentes. Entiendo además que la información que he proporcionado aquí NO se considerará en ninguna decisión de contratación, excepto por motivos de falsificación. Con mi firma a continuación, ratifico mi entendimiento de estos hechos y certifico además que toda la información que he proporcionado es fiel y correcta. Por la presente autorizo a todas las personas, escuelas, todos los ex empleadores, organizaciones, organismos de orden público o cualquier otra entidad que tiene información sobre mí, a que proporcionen ya sea verbalmente o por escrito a la compañía, sus agentes y cesionarios, toda la información de antecedentes pertinentes que se ha considerado necesaria para que la compañía tome una decisión de empleo. Asimismo, acepto mantener a la compañía, sus agentes, cesionarios y cualquier otra persona o entidad que divulgue la información antes mencionada, indemne y acepto eximirlos de responsabilidad que surja de dicha investigación de antecedentes. Una fotocopia o un facsímil de este formulario original servirán como autorización. Firma: Fecha: Application for Employment Page 8 of 10 Updated

9 Para informacion en espanol, visite www. ftc.gov/credit o escribe a l a FTC Consumer Response Center, Room 130-A 600 Pennsylvania Ave. N.W., Washington, D.C 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 or write to: Consumer Response Center, Room 130-A, Federal Trade Commission, 600 Pensylvania Ave. N.W., Washington, D.C 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, 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: o o o o o a person has taken adverse action against you because of information in your credit reports; 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. 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. 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 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 You may be limited "prescreened" offers of credit and insurance you get based on information in your credit report. Unsolicited "prescreened" offers for credit and insurance must be included 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 optout ( ). Application for Employment Page 9 of 10 Updated

10 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 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. Federal enforcers are: Type of Business: Consumer reporting agencies, creditors and others not listed below National banks, federal branches/agencies of foreign banks (word "Nationals" or initials "N.A." appear in or after bank's name) Federal Reserve System member banks (except national banks, and federal branches/agencies of foreign banks) Savings associations and federally chartered savings banks (word "Federal" or initials "F.S.B." appear in federal institution's name) Contact: Federal Trade Commission: Consumer Response Center FCRA Washington, DC Office of the Comptroller of the Currency Compliance Management, Mail Stop 6-6 Washington, DC Federal Reserve Board Division of Consumer & Community Affairs Washington, DC Office of Thrift Supervision Consumer Complaints Washington, DC Federal credit unions (words "Federal Credit Union" appear in institution's name) State-chartered banks that are not members of the Federal Reserve System Air, surface, or rail common carriers regulated by former Civil Aeronautics Board or Interstate Commerce Commission Activities subject to the Packers and Stockyard Act, 1921 National Credit Union Administration 1775 Duke Street Alexandria, VA Federal Deposit Insurance Corporation Consumer Response Center, 2345 Grand Avenue, Suite 100 Kansas City, MO Department of Transportation, Office of Financial Management Washington, DC Department of Agriculture Office of Deputy Administrator- GIPSA Washington, DC Application for Employment Page 10 of 10 Updated