Employment History

List below your last 3 employers, starting with the most recent one first

Education Information

General

Personal References

PLEASE NOTE

Driver’s Privacy Protection Act Compliance (DPPA)

I am aware that Motor Vehicle Reports may be obtained as part of my job application and/or employment. The reports may be procured by BASCA, Inc., and will include my driving record and an assessment of my insurability for BASCA’s insurance program. By signing this notice, I hereby provide my authorization for BASCA, Inc. to procure such information to evaluate my insurability.

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

Conditions of Employment 1. I authorize the investigation of all statements contained in this application. I understand that misrepresentation or material omission of facts is cause for dismissal, whenever such falsification or omission is discovered. I authorize all my previous employers and references to furnish any information concerning my personal character, habits or employment records. I release all such persons from liability or damages incurred as a result of this inquiry and furnishing this information. I further understand that any information omitted from this application could be considered grounds for immediate termination. 2. I understand and agree that my employment is for no definite period and may be terminated by me or BASCA, Inc. at any time, for any reason, with or without cause or previous notice, regardless of the date of payment of my wages and salary. I also acknowledge that any offer of employment or my acceptance of any employment offer, may be withdrawn for any reason at any time, and without prior notice at the option of BASCA, Inc. or me. No one can create a contract of employment either expressed or implied except in writing specifically to me. 3. If employed by BASCA, Inc., I will comply with all rules, regulations, and directives. I further understand that these rules and regulations may be changed, interpreted, withdrawn, or added to by BASCA, Inc. at any time, at BASCA, Inc.‘s sole option and without any prior notice to me. 4. In making this application for employment, I understand that a routine investigative report may be made. This inquiry includes information as to my character, general reputation, personal characteristics, and mode of living, whichever may be applicable. In addition, the report includes a criminal record check, motor vehicle record (MVR), education verification, and a public records check. I further understand that information obtained as part of this report may be considered grounds for immediate termination. 5. I voluntarily agree to submit to a drug test as part of my application for employment, if requested to do so. I understand that refusal to submit to the test or failure to pass the test according to the standards established by BASCA, Inc. will disqualify me from further consideration for employment. I further understand that I may again be required to submit to a drug test during my employment with BASCA, Inc. and if I refuse to take the test or fail to pass it according to the standards set by BASCA, Inc., I may be suspended or terminated immediately.

BASCA is an Equal Opportunity Employer

352 Stowe Ave, Orange Park FL 32073 Office: 904-541-1742 www.bascainc.org Fax: 904-278-6686