Internal Use Only:
Job Offer Date: ________________
Job Offer By: __________________Start Date: ____________________BARTOW PRECAST, INC.
APLICACION DE EMPLEO

En el cumplimiento de las leyes de igualdad en la oportunidad de empleo federales y estatales,
los aplicantes calificados serán considerados para las posiciones vacantes sin importar raza, color,religion, sexo, nacionalidad, edad, estado marital, estado veterano, discapacidad que no es enrelación con el trabajo, o cualquier otro grupo protegido.

Nombre del Aplicante:_______________________________ Fecha:________________(Nombres)(Apellidos)
Seguro Social #:_____________________ Posición a la que aplica:_________________
Dirección:_______________________________________ Desde cuándo:____________(Calle) (Ciudad) (Estado y código postal)
Dirección de Correo Postal (si es difiere con la dirección de la residencia):___________
Telefono#__________________________ Correo electrónico:_____________________EDUCACION
Nivel de Escuela: _______________________________________________________
Nombre de Escuela:_____________________________________________________
Ciudad/Estado: ______________ Área de Estudio o diplomado:____________MENCIONA HABILIDADES CON MAQUINARIA, EQUIPO, CURSOS, CONOCIMIENTOSADICIONALES O CLASES QUE SEAN RELEVANTES PARA LA POSICIÓN A LA CUAL
APLICA:HISTORIAL DE EMPLEO
Deben incluir dirección completa y número de teléfono. No se considerarán aquellos
candidatos cuyo historial de empleo no se pueda verificar. Enliste sus empleadores en orden
inverso, es decir empezando por el más reciente, si hay tiempo entre los trabajos donde no
se trabajo deberá explicar el motivo.

Nombre del Empleador:________________________________ Teléfono:____________
Contacto:_________________________ correo electrónico:_______________________
Puesto:____________________________ Desde:_____________ Hasta:_____________
Responsabilidades:________________________________________________________
Razones de retiro:_________________________________________________________

Nombre del Empleador:________________________________ Teléfono:____________
Contacto:_________________________ correo electrónico:_______________________
Puesto:____________________________ Desde:_____________ Hasta:_____________
Responsabilidades:________________________________________________________
Razones de retiro:_________________________________________________________

Nombre del Empleador:________________________________ Teléfono:____________
Contacto:_________________________ correo electrónico:_______________________
Puesto:____________________________ Desde:_____________ Hasta:_____________
Responsabilidades:________________________________________________________
Razones de retiro:_________________________________________________________Ha servido en las fuerzas armadas de EE.UU.? SI___ No___ Sirviendo actualmente___
EXISTE ALGUNA RAZÓN POR LA CUAL USTED SERÍA INCAPAZ DEREALIZAR EL TRABAJO QUE ESTÁ SOLICITANDO? SI_____ NO_____
Si su respuesta es afirmativa por favor explique:Es usted mayor de 18? Si___ No___ Si su respuesta es no, puede comprobar su edad?
Si___ No___TIENE USTED DERECHO LEGAL DE TRABAJAR EN LOS ESTADOS UNIDOS?
SI___ NO___BARTOW PRECAST, INC. ES UN LUGAR DE TRABAJO LIBRE DE DROGASCERTIFICADA. SI ES CONTRATADO, ESTA DISPUESTO A SOMETERSE A PASAR UNA
PRUEBA DE SUSTANCIAS? SI___ NO___PARA SER LEÍDO Y FIRMADO POR EL ASPIRANTE
Autorizo a BARTOW PRECAST, INC. para hacer tales investigaciones y consultas de mipersona, empleo, financieras y otras cuestiones en relación que sean necesarias para llegar a
una decisión de empleo. Por la presente libero a los empleadores, escuelas y otras personasde toda responsabilidad en responder a las preguntas y compartir información con respecto
a mi solicitud de empleo. En caso de empleo, entiendo que la información falsa o engañosa
proporcionada en mi solicitud o entrevista(s) puede resultar en el despido. Entiendo queestoy obligado a cumplir con todas las normas y reglamentos de la Compañía. También
certifico que he completado esta solicitud y que todas las entradas de información que
contiene son verdaderas y completas según mi leal saber y entender.
FIRMA:________________________________ FECHA:_______________________BARTOW PRECAST, INC.
Formulario de consentimiento de prueba de drogas
y liberación de resultados previos al empleo

Por medio de la presente doy mi consentimiento para someterme al análisis de orina
y/u otras pruebas según lo determine BARTOW PRECAST, INC. en el proceso deselección de solicitantes de empleo, con el fin de determinar el contenido de drogas en
los mismos.
Acepto que la compañía Cartersville 2FFXSDWLRQDO0HGLFLQH (u otra empresa
contratada por la Compañía) puede recolectar estas muestras para estas pruebas ypuede analizarlas o enviarlas a un laboratorio de pruebas para su análisis.
Además, por medio de la presente acepto y autorizo la divulgación de los resultados dedichas pruebas a la Compañía.
Entiendo que el uso actual de drogas ilegales es lo que me prohibiría trabajar en esta
Compañía.
Además, acepto mantener indemne a la Compañía y a sus agentes (incluido el médico
o la clínica antes mencionados) de cualquier responsabilidad total o parcialmente que
surja de la recolección de muestras, las pruebas y el uso de la información de dichas
pruebas en relación con la consideración de la Compañía y mi solicitud de empleo.
Además, acepto que una copia reproducida de este Formulario de autorización yconsentimiento previo al empleo tendrá la misma fuerza y efecto que el documento
original.
He leído cuidadosamente lo que antecede y entiendo completamente su contenido.
Reconozco que mi firma de este Formulario de consentimiento y divulgación es un acto
voluntario de mi parte y que nadie me ha obligado a firmar este documento.

APLICANTE:
Nombre en letra molde:
Firma:TESTIGO:
Nombre en letra molde:
Firma:

S.S. #:
Fecha:

Bartow Precast, Inc.

Company Name:________________________________________DISCLOSURE REGARDING BACKGROUND INVESTIGATION

Employer (the “Company”) may obtain a consumer report about you from a consumer
reporting agency for employment purposes (including contract or volunteer services) and if you
are hired, or if you already work for the Company, may obtain additional consumer reports on
you for employment purposes.
The Company may order an “investigative consumer report.” Such reports typically include
information from personal interviews, most commonly from an applicant’s prior employers andreferences.
The report may include information about your character, general reputation, personal
characteristics, and/or mode of living. Information may be obtained from private and publicrecord sources. These reports may contain information regarding your criminal history, social
security verification, motor vehicle records (‘driving records’), credit reports, verification of youreducation or employment history (including income), or other background checks.
You have the right to request more information about the nature and scope of a consumer
report, if any, by contacting Professional Screening & Information, Inc., P.O. Box 644, Rome,
Georgia 30162 by calling them collect at 1-877-235-7574, or contacting them via the internet atwww.psibackgroundcheck.com.

A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACTPara informacion en espafiol, visite www.consumerfinance.QOv/learnmore o escribe a la Consumer Financial Protection Bureau, 1700 G
Street N.W., Washington, DC 20552.

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 asagencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of yourmajor rights under FCRA. For more Information, including information about additional rights, go towww.consumerflnance.QOv/tearnmore or write to: Consumer Financial Protection Bureau, 1700 G Street N.W.,

Washington, DC 20552.

• 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 - musttell 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 flle.You may request and obtain all the information about you in the files of aconsumer 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:• a person has taken adverse
action against you because of information in your credit report; • you are the victim of identity theft and place a fraud alert In yourfile; • 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. In addition, all consumers are entitled to one free disclosure every 12 months uponrequest from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See
www.cQnsumerfinance.aov/learnmore for additional information.

• 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 distributescores used In residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive creditscore 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
www.consumerfinance.Qov/learnmore 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 www.consumerfinance.qov/learnmore.
• You may limit '"prescreened" offers of credit and insurance you get based on information in your credit report.
Unsolicited "prescreened" offers for credit and insurance must include a toll-free phone number you can call if you choose to remove
your name and address form the lists these offers are based on. You may opt out with the nationwide credit bureaus at 1-888-5-OPTOUT(1-888-567-8688).
CONSUMERS HAVE THE RIGHT TO OBTAIN A SECURITY FREEZE

You have a right to place a "security freeze" on your credit report, which will prohibit a consumer reporting agency
from releasing information in your credit report without your express authorization. The security freeze is designed toprevent credit, loans, and services from being approved in your name without your consent. However, you should be aware that using asecurity freeze to take control over who gets access to the personal and financial information in your credit report may delay, interfere
with, or prohibit the timely approval of any subsequent request or application you make regarding a new loan, credit, mortgage, or any
other account involving the extension of credit.

As an alternative to a security freeze, you have the right to place an initial or extended fraud alert on your credit file at no cost. An
initial fraud alert Is a 1-year alert that is placed on a consumer's credit file. Upon seeing a fraud alert display on a consumer's credit file,a business is required to take steps to verify the consumer's identity before extending new credit. If you are a victim of identity theft,
you are entitled to an extended fraud alert, which is a fraud alert lasting 7 years.
A security freeze does not apply to a person or entity, or its affiliates, or collection agencies acting on behalf of the person or entity, withwhich you have an existing account that requests information in your credit report for the purposes of reviewing or collecting theaccount. Reviewing the account includes activities related to account maintenance, monitoring, credit line increases, and accountupgrades and enhancements.

• You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or afurnisher 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
www.consumerfinance.aov/learnmore.

States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may© Copyright. Professional Screening & Information, Inc.

have more rights under state law. For more information, contact your state or iocai consumer protection agency or
your state Attorney Generai. For information about your federai rights, contact:
FOR QUESTIONS OR CONCERNS REGARDING:PLEASE CONTACT:

1. a. Banks, savings associations, and credit unions with total assets ofa. Consumer Financial Protection Bureau 1700 G Street NW

over $10 billion and their affiliates, b. Such affiliates that are not banks, Washington, DC 20006 b. Federal Trade Commission
savings associations, or credit unions also should list, in addition to the
CFPB:

2. To the extent not included in item 1 above:a. National banks,

Consumer Response Center 600 Pennsylvania Avenue,
N.W. Washington, DC 20580 (877) 382-4357
a. Office of the Comptroller of the Currency Customer

federal savings associations, and federal branches and federal agencies Assistance Group 1301 McKlnney Street, Suite 3450
of foreign banks
b. State member banks, branches and agencies of
Houston, TX 77010-9050 b. Federal Reserve Consumer
foreign banks (other than federal branches, federal agencies, andHelp Center P.O. Box 1200 Minneapolis, MN 55480 c. FDIC
Insured State Branches of Foreign Banks), commercial lending
companies owned or controlled by foreign banks, and organizations

Consumer Response Center 1100 Walnut Street, Box #11
Kansas City, MO 64106 d. National Credit Union

operating under section 25 or 25A of the Federal Reserve Act.

Administration Office of Consumer Protection (OCP)
Division of Consumer Compliance and Outreach (DCCO)

c.

Nonmember Insured Banks, Insured State Branches of Foreign Banks,and insured state savings associations
d. Federal Credit Unions

1775 Duke Street Alexandria, VA 22314
Asst. General Counsel for Aviation Enforcement &3. Air Carriers

4. Creditors Subject to Surface Transportation Board

5. Creditors Subject to Packers and Stockyards Act, 1921

Proceedings Aviation Consumer Protection Division
Department of Transportation 1200 New Jersey Avenue,
S.E. Washington, DC 20590

Office of Proceedings, Surface Transportation Board
Department of Transportation 395 E Street, S.W.
Washington, DC 20423
Nearest Packers and Stockyards Administration area
supervisor

6. Small Business Investment Companies

Associate Deputy Administrator for Capital Access UnitedStates Small Business Administration 409 Third Street,
S.W., Suite 8200 Washington, DC 20416

7. Brokers and Dealers

Securities and Exchange Commission 100 F Street N.E.
Washington, DC 20549

8. Federal Land Banks, Federal Land Bank Associations, Federal
Intermediate Credit Banks, and Production Credit Associations
9. Retailers, Finance Companies, and All Other Creditors Not Listed
Above

Farm Credit Administration 1501 Farm Credit Drive

McLean, VA 22102-5090

Federal Trade Commission Consumer Response Center
600 Pennsylvania Avenue, N.W. Washington, DC 20580(877) 382-4357

Questions and/or consumer referrals may be made to:Professional Screening & Information, Inc, Post Office Box 644 Rome, Georgia 30162 Telephone (toll free): 706-235-7574 OR 1-877-2357574

Thank you for allowing us the opportunity to serve as your background investigation provider.

© Copyright. Professional Screening & Information, Inc.

CONSUMER REPORT AUTHORIZATIONThe company with whom You have applied (the “Company”) intends to procure one or more consumer
reports, or investigative consumer reports, about You in connection with your application for
employment and requires your consent in order to do so.
By signing below, you acknowledge and affirm as follows:I hereby authorize the Company to procure one or more consumer reports, and/or investigative
consumer reports, which may include criminal background history, about me to be used for
employment purposes at any time after receipt of this authorization and, if I am hired, throughout myemployment as allowed by law.
To that end, I hereby authorize, as allowed by law, any law enforcement agency, administrator, state orfederal agency, institution, school or university (public or private), information service bureau, employer
or insurance company to furnish any and all background information requested by Professional
Screening & Information, Inc., another outside organization acting on behalf of Company and/orCompany itself.
I agree that this Consumer Report Authorization in its original, faxed, photocopied, or electronic form
will be valid for any consumer reports or investigative consumer reports that may be requested about
me on behalf of the Company.
I understand that my driving record may be used to verify my identity and/or my ability to drive legallyand safely. If driving a company vehicle (or my own vehicle) is a requirement of the position I am being
considered for, then having and maintaining a satisfactory driving record and being able to legally andsafely drive as required by my employer is a condition of my employment. If applicable, I agree to allow
the Company to check my driving record, which may contain information about my physical, mental, or
behavioral health maintained by a state government agency that has restricted by ability to drive legally,prior to hire and periodically thereafter.
I acknowledge receipt of the following documents: “Disclosure Regarding Background Investigation”,“State Disclosures”, and “A Summary of Your Rights Under the Fair Credit Reporting Act”.
I understand I have the following rights in connection with this Authorization: You have the right,
upon written request made within a reasonable time after receipt of this notice to ask the Company todisclose the nature and scope of any consumer report. You may also request a copy of that report fromthe Company. You may also request a copy from Professional Screening & Information, Inc., P.O. Box644, Rome, Georgia 30162 by calling them collect at 1-877-235-7574, or contacting them via theinternet at www.psibackgroundcheck.com. If anyone other than Professional Screening & information,
Inc. provides an investigative consumer report about you, the Company will provide you with theirrelevant contact information within five days of your request.
BY SIGNING BELOW, I AFFIRM THAT EACH OF THE ABOVE IS TRUE AND CORRECT:______________________________________________________________
NAME

DATE

THE INFORMATION BEING REQUESTED BELOW IS FOR BACKGROUND INVESTIGATION PURPOSES ONLY AND WILL NOT BE USEDFOR ANY OTHER PURPOSE.

PLEASE PRINT
Full Legal Name (as shown on SSN / ID card):
First: _____________________________ Middle: ____________________________ Last: _________________________
Additional Name: (First, Middle Last): ___________________________________ Dates Used (from-to): ______________
Social Security Number: __________ - _______ - __________ Date of Birth (month-day-yr): ______ - ______ - ________
Driver’s License Number: ____________________________ State: _______
Cell #: ____________________________ Home #: ______________________________
E-mail Address: ___________________________________________________________
Position Applied For: _________________________________________________________________________________

Current Address:

Month / Year Street: ______________________________________________________________

From: __________________

City, State, County, Zip:_________________________________________________

To: ____________________

Chronologically list ALL places of residence for the past seven years: Street: _________________________________________________________________

From: __________________

City, State, County, Zip:____________________________________________________

To: ____________________

 Street: _________________________________________________________________

From: __________________

City, State, County, Zip:____________________________________________________

To: ____________________

 Street: _________________________________________________________________

From: __________________

City, State, County, Zip:____________________________________________________

To: ____________________COMPANY USE ONLY
Client: Bartow Precast, Inc.

Location: _______________

Note: PLEASE NOTE: For all Motor Vehicle Reports, a clear and legible copy of the applicant’s driver’s license isrequired.