APPLICATION FOR EMPLOYMENT

The individual requesting qualification with Great Deal Movers (GDM) must complete the rest of this Request for Qualification. Any falsification or incomplete information may result in the Request being rejected and/or shall be grounds for terminating the relationship. In order that your Request may be properly evaluated, it is essential that all of the following information be answered carefully and completely. Applicants will be considered regardless of race, sex, age, religion, national origin, marital status, disability or veteran’s status, or any other basis prohibited by federal, state, or local law. We do not tolerate discrimination

EDUCATION

FORMER RESIDENCE: List last two (2) years of former residence. (Use back of sheet if necessary)

PERSONAL WORK REFERENCES: List two (2) additional references that can also be used to verify unemployment, self-employment, or previous employers that are no longer in business.

Personal Information

Agreement and Authorization To Release Information And Records (To be read and signed by the prospective candidate)

I hereby release all parties, including but not limited to GDM, its parent company and their related entities, employees, officers, directors, agents, my personal referenced and previous employers (collectively referred to as Releasees) from any and all liability including, but not limited to, attorney’s fees and costs, any injury or damage that may result from Releasees furnishing information concerning me or any action by releasees taken on the basis of such information.

I agree to submit to a medical examination including a controlled substance test. I understand that if I fail to satisfactorily pass any part of the medical examination I will be rejected. Any positive results obtained from my controlled substance test shall result in the rejection of my request. My signature on this request indicates that I fully understand my responsibility concerning GDM’s drug policy and GDM’s commitment to a drug-free workplace and that I agree to abide by these policies.

I agree to familiarize myself with and to abide by all present and subsequently revised rules, policies, and/or procedures of GDM, its agents, and all regulations of the United States.

I understand that this Request is not intended to be a contract. I further understand that statements that may be contained in policies, practices, or other GDM material do not create any contractual guarantee and that GDM has the right to modify, amend or terminate policies, practices, benefit plans, or other GDM programs within the limits and requirement imposed by law. This certifies that this Request was completed by me and that all entries on it and information in it are true and complete to the best of my knowledge. In the event my request is accepted, I understand that false, misleading, or omitted information may result in rejection of my Request and/or termination.

I hereby authorize Great Deal Movers or its designated agents, to conduct a thorough investigation of my past employment, education, criminal history, credit history, workers compensation history, motor vehicle records, references and activities as needed to determine my qualification with GDM. I authorize all persons who may have information relevant to this investigation to disclose such information to GDM or its agents. This specifically includes the release of information by my present and former employers (listed on pages 3 & 4 of this request), law enforcement agencies, courts, criminal justice agencies, educational institutions, financial institutions, military records, landlords, creditors, and others, whether or not specifically mentioned herein. I hereby release any individual, including record custodians, from any and all liability for damages of whatever kind or nature which may at any time result to me on account of compliance, or any attempts to comply with this authorization. I also understand and agree that APM may share personal information with other organizations as required or permitted by law.

I understand the information I provide regarding current and/or previous employers may be used, and those employers will be contacted for the purpose of investigating my performance history. I understand that I have the right to review the information provided by previous employers; To have errors in the information corrected by the previous employers and for that previous employer to re-send the corrected information to the prospective employer; Have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the applicant cannot agree on the accuracy of the information.

I understand that as a condition of being certified to drive interstate under the operating authority for GDM, I must give GDM written authorization to obtain the results of any and all drug and/or alcohol tests during the past three (3) years as required by 49 CFR 382.413 & 40.25. This authorization applies to all employers (listed on pages 3 & 4 of this request). And applies to: Verified positive drug tests; Alcohol tests with a confirmed breath alcohol concentration of 0.04 or greater; Refusals to be testing regulations.

I understand that my signing of this authorization signifies I have read and fully understand this authorization and give my voluntary approval to release my information as needed for employment with GDM. In signing below, I certify that all of the information which I have furnished on this form is true and complete to my knowledge. Reproduction of this authorization shall be valid as the signed original and it does not carry an expiration date.