Employment Application — Rush Innovations Corp

Position & Contact Information

Position applying for *

First name * Middle initial Last name * Date available to start

Cell phone * Home phone

Email address * Street address *

City * State * ZIP code * Salary / pay rate desired

Driver's license number License state

Are you authorized to work in the U.S. on an unrestricted basis? *

Yes No

How did you hear about us?

Education & Qualifications

High School / GED

School name & location Year completed

Completed?

Yes No

College / University

School name & location Degree

Graduated?

Yes No

Vocational / Technical / Other

School name & location Certificate

Graduated?

Yes No

Special skills / certifications / relevant experience

Professional References

Please provide at least two professional references.

Reference 1

Full name * City / State Phone number * Relationship

Reference 2

Full name * City / State Phone number * Relationship

Reference 3 (optional)

Full name City / State Phone number Relationship

Work History (most recent first)

Job 1

Job title * Company name & address From (MM/YY) To (MM/YY or “present”) Supervisor name & phone Salary (start / end) Ending salary Reason for leaving

May we contact this employer?

Yes No N/A

Key responsibilities & duties

Job 2 (optional)

Job title Company name & address From (MM/YY) To (MM/YY or “present”) Supervisor name & phone Salary (start / end) Ending salary Reason for leaving

May we contact this employer?

Yes No N/A

Key responsibilities & duties

Job 3 (optional)

Job title Company name & address From (MM/YY) To (MM/YY or “present”) Supervisor name & phone Salary (start / end) Ending salary Reason for leaving

May we contact this employer?

Yes No N/A

Key responsibilities & duties

Position Screening & Requirements

1) Do you have a current, valid driver's license? *

Yes No

2) Has your driver's license ever been suspended, revoked, or restricted? *

Yes No

3) Do you hold a Commercial Driver's License (CDL)? *

Yes No

4) Do you consent to Rush Innovations obtaining your motor vehicle record (MVR)? *

Yes No

5) Do you have your own reliable transportation to and from work? *

Yes No

6) Do you carry auto liability insurance of at least $100,000 per person / $300,000 per accident? *

Yes No

7) Are there any essential functions of the position you are applying for that you cannot perform, with or without reasonable accommodation? *

Yes No

Essential Job Functions

Every position at Rush Innovations has a written list of essential functions. If you need an accommodation to perform any of them, telling us here lets us work it out with you — it does not count against your application.

Are there any essential functions of the position you are applying for that you cannot perform, with or without reasonable accommodation? *

Yes No

Background Screening Information

Rush Innovations runs a criminal background check and a motor vehicle record check on every hire. This information is used only for that screening and is stored encrypted.

We are not asking for your Social Security number here. We only need it if we hire you, and you will enter it then, on your tax forms.

Date of birth * Maiden or other name(s) used

Address history

How long at your current address? If under 7 years, list previous addresses.

Time at current address

Previous address 1 How long? Previous address 2 How long?

Have you been convicted of or pled guilty to a crime in the last 7 years? *

Yes No

May we contact your present employer?

Yes No

I am a resident of Minnesota, California, or Oklahoma and would like a copy of the investigative report.

Certification & Signature

Applicant Certification

I certify that the facts set forth in this Application for Employment are true and complete to the best of my knowledge. I understand that if employed, false statements, omissions, or misrepresentations may result in dismissal. I authorize Rush Innovations Corp to make an investigation of any facts set forth in this application and release the Employer from any liability. I acknowledge and understand that Rush Innovations Corp is an 'at-will' employer.

I have read and agree to the certification above. *

Authorization & Consent for Release of Information

Read the full background screening consent

It is a condition of employment, and/or continued employment, that all applicants consent to and authorize a verification of the information submitted on their application or resume. This release and authorization acknowledges that Rush Innovations Corp may now, or at any time while I am employed, conduct a verification of my education, employment history, and/or motor vehicle records; contact personal references; require that I provide a specimen to be tested for the presence of drugs or alcohol; and receive any criminal history record information pertaining to me from any Federal, State or Local criminal justice agency. If an offer of employment has been made, I authorize review of my worker's compensation claim history. I authorize persons, schools, current and former employers, and other organizations and agencies to provide a consumer reporting agency acting on behalf of Rush Innovations Corp with all information that may be requested, and I hereby release all of the persons and agencies providing such information from any and all claims and damages connected with their release of any requested information. I agree that any copy of this document is as valid as the original. According to the Federal Fair Credit Reporting Act, I am entitled to know if employment was denied based on information obtained by my prospective employer, and to receive, upon written request, a disclosure of the public record information and of the nature and scope of the investigative report.

I authorize the background verification described above. *

Your Signature *

Your electronic signature is applied to the application and the background screening consent.