Personal Information

Present Address

Permanent Address

Employment Desired



Exclude organizations, the name of which indicates the race, creed, sex, age, marital status, color or nation of origin of its members

Former Employers


Give the name of three persons not related to you whom, you have known at least one year.

Disclosure and Release Form

In connection with my application for employment (including contract for services or volunteer services) or tenancy with Kugler Oil Company, at 209 West Third Street McCook, NE 69001, consumer reports will be requested. These consumer reports (investigative consumer reports in California) may include the following types of information: names and dates of previous employers, salary, work experience, education, accidents, licensure, credit (except California), etc. I further understand that such reports may contain public record information such as, but not limited to: my driving record, workers’ compensation claims, judgements, bankruptcy proceedings, criminal records, etc., from federal, state and other agencies which maintain such records. In addition, investigative consumer reports as defined by federal Fair Credit Reporting Act, gathered from personal interviews with former employers and other past or current associates of mine to gather information regarding my work performance, character, general reputation and personal characteristics, may be obtained. I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY THE CONSUMER REPORTING AGENCY TO FURNISH THE ABOVE-MENTIONED INFORMATION. I have the right to make a request to the consumer reporting agency: Background Screeners of America, 18344 Oxnard Street, Suite 101, Tarzana, CA 91356; telephone (866) 570-4949) (“Agency”), upon proper identification, 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 our behalf, will provide a complete and accurate disclosure of the nature and scope of the investigation covered by the investigative consumer report(s); and the recipients of any 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 your obtaining the above information from the agency. You may view their privacy at their website: I hereby authorize procurement of consumer report(s) and investigative consumer report(s). If hired (or contracted), this authorization shall remain on file and shall serve as ongoing authorization for you to procure consumer reports at any time during my employment (or contract) period.

Notice to California Applicants:

You 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 your file for your review. You may obtain such information as follows: 1) In person at the Agency’s offices, which address is listed above. You can have someone accompany you to the Agency offices. Agency may require this third party to present reasonable identification. You may be required at the time of such visit to sign an authorization for Agency to disclose to or discuss your information with this third party; 2) By certified mail, if you have previously provided identification in a written request that your file be sent to you or to a third party identified by you; 3) By telephone, if you have previously provided proper identification in writing to Agency; and 4) Agency has trained personnel to explain any information in your file to you and if the file contains any information that is coded, such will be explained to you.

Notice to New York Applicants:

For consumers applying for work in New York:

I acknowledge receiving a copy of Article 23-A of the New York Correction Law

Pre-Employment Substance Testing Consent Form

As a condition for an application to be considered, applicants must understand and agree to submit to a drug and/or alcohol test. If the test results are positive, the applicant shall not be considered further by the Kugler Company for employment. The Kugler Company will pay the cost of the pre-employment drug/alcohol test. Any additional treatment or cost relating to the results of the testing is the applicant's responsibility.

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