Applicant's Disclosure & Authorization For Background Screening and Vehicle Safety & Image Checklist
| Location |
1391 110 Oakbrooke Drive Mount Washington, KY 40047 5025433888 |
| Supervisor Email: | [email protected] |
| DTID PIZZA INC., DTID WOLVERINE PIZZA LLC, DTID KENTUCKY PIZZA LLC | |
| APPLICANT'S DISCLOSURE & AUTHORIZATION FOR BACKGROUND SCREENING | |
| Account Number 101-108647 | |
| Position Applied for: | Delivery Driver |
| Applicant Name: (First Middle Last) |
Stephanie Shine Herbst
|
| Other Name(s) Used: (like Maiden) | |
| *Gender: | Female |
| *Social Security Number: |
308152250
|
| Driver's License Number: | |
| State: |
Kentucky
|
| *Date of Birth: | March 13, 1994 |
| Place of Birth: (City, State, Country) |
Fort Wayne, IN, USA
|
| Current Address: (street address) |
343 Meadows Drive
|
| City: |
Mount Washington
|
| State: |
Kentucky
|
| Zip: |
40047
|
| Former Address: (1) |
343 Meadows Drive
|
| City: |
Mount Washington
|
| State: |
Kentucky
|
| Zip: |
40047
|
| Former Address: (2) | |
| City: | |
| State: | |
| Zip: | |
| *This information will be used for purposes of background screening only and will not be used in making any employment decisions. | |
| DISCLOSURE REGARDING BACKGROUND INVESTIGATION | |
| Employer ("the Company") may obtain information about you from a consumer reporting agency for employment purposes. Thus, you may be the subject of a "consumer report" and/or an "investigative consumer report" which may include information about your character, general reputation, personal characteristics, and/or mode of living, and which can involve personal interviews with sources such as your neighbors, friends, or associates, including motor vehicle record (or "driving record") checks, workers compensation records, credit bureau files, employment references, personal references, social networking (i.e. Facebook, Twitter), drug screening, any educational and licensing institution or military branch and to receive any criminal record information pertaining to you which may be in the files of any federal, state or local criminal justice agency in any state. Credit reports will only be requested where such information is substantially related to the duties and responsibilities of the position for which you are applying. These reports may be obtained at any time after receipt of your signed authorization and, if you are hired, throughout your employment. An "investigative consumer report" includes information from personal interviews, except in California where that term means any consumer report. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report and to request a copy of your report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your education and/or employment history conducted by InfoMart, 1582 Terrell Mill Road, Marietta, GA 30067, 800-800-3774 www.infomart-usa.com or another outside organization. The scope of this disclosure and authorization is all-encompassing, however, allowing Employer to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and, if you are hired, throughout the course of your employment to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report. | |
| New York and Maine applicants or employees only: You have the right to inspect and receive a copy of any investigative consumer report requested by Employer by contacting the consumer reporting agency identified directly above. You may also contact the Company to request the name, address and telephone number of the nearest unit of the consumer reporting agency designated to handle inquiries, which Employer shall provide within 5 days. | |
| New York applicants or employees only: Upon request, you will be informed whether or not a consumer report was requested by Employer, and if such report was requested, informed of the name and address of the consumer reporting agency that furnished the report. | |
| Oregon applicants or employees only: Information describing your rights under federal and Oregon law regarding consumer identity theft protection, the storage and disposal of your credit information, and remedies available should you suspect or find that Employer has not maintained secured records is available to you upon request. | |
| Washington State applicants or employees only: Under the Washington Fair Credit Reporting Act, you have the right to ask InfoMart for a written summary of your rights. If you submit a request to Employer in writing, you have the right to get from Employer a complete and accurate disclosure of the nature and scope of the investigative consumer report Employer ordered, if any. If Employer obtains information bearing on your credit worthiness, credit standing or credit capacity, it will be used to evaluate whether you would present an unacceptable risk of theft or other dishonest behavior in the job for which you are being considered. | |
| Minnesota and Oklahoma applicants or employees only: | |
| Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Company. | Not Checked |
| ACKNOWLEDGMENT AND AUTHORIZATION | |
| I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of "consumer reports" and/or "investigative consumer reports" at any time after receipt of this Acknowledgement and Authorization and, if I am hired, throughout my employment. I understand that, except in California, InfoMart, 1582 Terrell Mill Road, Marietta, GA 30067 800.800.3774 www.infomart-usa.com, and its agents, and/or another outside organization acting on behalf of Employer, and/or Employer itself may rely on this authorization to order additional consumer reports, including investigative consumer reports, from time to time during my employment, as deemed necessary for employment purposes and as allowed by law. I also authorize the following agencies and entities to disclose to InfoMart and its agents, and/or another outside organization acting on behalf of Employer, and/or Employer itself, all information about or concerning me, including, but not limited to: my past or present employers; learning institutions, including colleges and universities; law enforcement and all other federal, state and local agencies; federal, state and local courts; the military; credit bureaus; insurance companies; testing facilities; motor vehicle records agencies; all other private and public sector repositories of information; and any other person, organization, or agency with any information about or concerning me. The information that can be disclosed includes, but is not limited to, information concerning my employment history, earnings history, education, credit history, motor vehicle history, criminal history, military service, drug testing results, and professional credentials and licenses. I agree that a facsimile ("fax") or photographic copy of this Acknowledgement and Authorization shall be as valid as the original. | |
| New York applicants or employees only: By signing below, you also acknowledge receipt of Article 23-A of the New York Correction Law. | |
| California applicants or employees only: | |
| By signing, you also acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION AND CREDIT CHECKS PURSUANT TO CALIFORNIA LAW. Please check this box if you would like to receive a copy of an investigative consumer report or consumer credit report if one is obtained by the Company at no charge whenever you have a right to receive such a copy under California law. | Not Checked |
| APPLICANT | |
Signature:
|
|
| Date: | April 2, 2021 |
| Name: |
Stephanie
|
| VEHICLE SAFETY & IMAGE CHECKLIST | |
| Driver's Name: |
Stephanie Shine Herbst
|
| Driver's License/State: |
H12-247-635
|
| Vehicle Tag: |
889WBE
|
| State: |
KY
|
| Year/Make: |
2009 Chevy
|
| Owner's Name: |
Stephanie Herbst
|
| If not Driver, permission to drive on file: | |
| Insurance Company: |
Progressive
|
| Policy #: |
945498672
|
| Expires: |
7/12/2021
|
| SAFETY | |
| Brake Lights | Yes |
| Notes | |
| Tail Lights | Yes |
| Notes | |
| Rear Turn Signals | Yes |
| Notes | |
| Reverse Lights | Yes |
| Notes | |
| Headlights | Yes |
| Notes | |
| High Beams | Yes |
| Notes | |
| Front Turn Signals | Yes |
| Notes | |
| Horn | Yes |
| Notes | |
| Windshield Wipers | Yes |
| Notes | |
| Tire Pressure & Tread | Yes |
| Notes | |
| Mirrors | Yes |
| Notes | |
| Driver's Seat Belt | Yes |
| Notes | |
| Brake Pedal Pressure | Yes |
| Notes | |
| IMAGE | |
| Body is in good repair | Yes |
| Notes | |
| Nothing offensive | Yes |
| Notes | |
| Exterior is clean | Yes |
| Notes | |
| Interior is clean | Yes |
| Notes | |
| Car Top Sign fits on roof | Yes |
| Notes | |
| Inspected By: |
Asia Stevens
|
Signature:
|
|
| Date: | April 2, 2021 |
| Inspector's Title: | GEN MGR |
| I will not use this vehicle for Domino's business purposes if it does not pass this inspection. I assume all responsibility for correcting every deficiency shown by this inspection, and I understand that, if corrections are needed, a Domino's supervisor must re-inspect this vehicle before I can use it for business purposes. | |
Driver's Signature:
|
|
| Date: | April 2, 2021 |
| Pictures of Driver's license, Insurance and Registration | |
| Photo of Drivers License | |
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| Photo of Insurance | |
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| Photo of Registration | |
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