Employer #2

Employer #3

Employer #4

Applicant's Statement

I have read and fully understand the questions asked in this application. I certify that all of the answers I have given are true, accurate and complete. I understand that the omission and/or misrepresentation of any fact from or on this application or during any interview will result in immediate rejection of my application or if I am hired will be cause for immediate dismissal. Unless I noted otherwise, I authorize the Company to independently contact all my employment references and personal references, as well as the education institutions I have attended. I further authorize the Company to independently inquire about, investigate and obtain copies of any records which relate to me from my former employers and educational institutions. I hereby release the Company and all affiliated persons and entities, as well as any person or institution that provides the Company with any lawful information about me, from any and all liability whatsoever resulting from any such lawful independent inquiry, investigation or communication.

If hired, I understand that I will be required to abide by all of the rules and regulations of the Company. I understand and agree that nothing in this application shall constitute an offer, a contract or a guarantee of employment for a specific period of time. If hired, I understand that my employment may be terminated with or without cause and with or without notice at any time, at the will of the Company or me. I further understand that no representative or agent of the Company, other than the Senior Vice President of Human Resources has the authority to enter into any agreement for employment, on an individual or collective basis, for any specific period of time, or to make an agreement contrary to the foregoing. I also understand that any agreement modifying at-will employment status, on an individual or collective basis, must be in writing and signed by the Senior Vice President of Human Resources. In addition, I understand that the Company and all plan administrators shall have the maximum discretion permitted by law to administer, interpret, modify, discontinue, enhance or otherwise change all policies, procedures, benefits or other terms and conditions of employment.

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Authorization For Consumer Reports

I hereby authorize procurement of consumer report(s) and investigative consumer report(s) by HallKeen Management “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 above-mentioned 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: Safer Places, Inc. (“Agency”), 25 Wareham Street; Suite 2-26; Middleboro, MA 02346; telephone number: 877-962-0600, upon proper identification, to obtain copies of any reports 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, including the sources of information, and the Agency, on Company’s behalf, will 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.SaferPlacesInc.com.

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:

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 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.

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Disclosure For Consumer Reports

In connection with my application for employment (including contract or volunteer services) with __________________, I understand consumer reports (investigative consumer reports in California) will be requested about me. 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, 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, workers’ compensation claims, judgments, bankruptcy proceedings, criminal records, etc., from federal, state, and other agencies that maintain such records.

CALIFORNIA: A consumer credit report will not be procured by California employers unless the position for employment meets the criteria for an exception. If employer intends to procure a consumer credit report in this case, check the box and indicate position that meets the exception criteria here: ________________________.

In addition, investigative consumer reports (gathered from personal interviews, as applicable, with former employers, former customers, past or current neighbors and associates of mine, etc.) to gather information regarding my work performance, character, general reputation and personal characteristics, and mode of living (lifestyle) may be obtained.

If I am hired, I understand that my employer can use this disclosure to continue to obtain such consumer reports/investigative consumer reports throughout my employment, contract period or volunteer service.

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Criminal Offender Record Information (CORI) Acknowledgement Form

To be used by organizations using consumer reporting agencies to conduct cori checks for employment, volunteer, subcontractor, licensing, and housing purposes

Hallkeen management is registered under the provisions of m.G.L. C. 6, § 172 to receive cori for the purpose of screening current and otherwise qualified prospective employees, subcontractors, volunteers, license applicants, current licensees, and applicants for the rental or lease of housing. Hallkeen management has authorized safer places, inc. To submit cori checks to the massachusetts department of criminal justice information services (DCJIS) on its behalf.

as a prospective or current employee, subcontractor, volunteer, license applicant, current licensee, or applicant for the rental or lease of housing, I understand that a cori check will be submitted for my personal information to the dcjis. I hereby acknowledge and provide permission to safer places, inc. To submit a cori check for my information to the dcjis. This authorization is valid for one year from the date of my signature.

I may withdraw this authorization at any time by providing hallkeen management & safer places, inc. With written notice of my intent to withdraw consent to a cori check. I also understand that this form is a cori acknowledgement form and I am entitled to additional consumer reporting disclosure forms under the fair credit reporting act. If I have not received those disclosures, I should contact safer places, inc. To request this information.

For employment, volunteer, and licensing purposes only: safer places, inc. On behalf of hallkeen management may conduct subsequent cori checks within one year of the date this form was signed by me provided, however, that hallkeen management & safer places, inc. Must first provide me with written notice of this check.

By signing below, I provide my consent to a cori check and acknowledge that the information provided on this acknowledgement form is true and accurate.

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