Employment Application

Western Express Lending
Date*
Last Name*
First Name*
Middle Name
Present Address
City
State
Zip
Permanent Address (if different from present address)
City
State
Zip
Cell Phone*
Home Phone
Social Security Number
Position applying for:
Regular full-time work?
- Yes
- No
Regular part-time work?
- Yes
- No
Temporary work, e.g., summer or holiday work?
- Yes
- No
What days and hours are you available for work?
If applying for temporary work, during what period of time will you be available?
Are you available for work on weekends?
- Yes
- No
Would you be available to work overtime, if necessary?
- Yes
- No
If hired, on what date can you start work?
Salary desired:

EMPLOYMENT HISTORY/CERTIFICATION
Answer the following questions if you are applying for a LICENSED OR CERTIFIED position:
Are you licensed/certified for the job applied for?
- Yes
- No
Name of license/certification:
Issuing state:
License/certification number
Has your license/certification ever been revoked or suspended?
- Yes
- No
If yes, state reason(s), date of revocation or suspension and date of reinstatement.
Employment History
List below all present and past employment starting with your most recent employer (last five years is sufficient). Account for all periods of unemployment. You must complete this section even if attaching a resume.
Name of Employer
Telephone No.
Type of Business
Your Supervisor's Name
Address & Street
City
State
Zip
Your Position and Duties
Reason for Leaving
May we contact this employer for a reference?
- Yes
- No
Name of Employer
Telephone No.
Type of Business
Your Supervisor's Name
Address & Street
City
State
Zip
Dates of Employment:
From
To
Weekly Pay:
Starting
Ending
Your Position and Duties
Reason for Leaving
May we contact this employer for a reference?
- Yes
- No

MILITARY HISTORY - REFERENCES
Have you obtained any special skills or abilities as the result of service in the military?
- Yes
- No
If so, describe:
References
List below three persons not related to you who have knowledge of your work performance within the last three years.
First Name
Last Name
Telephone No
Address & Street
City
State
Zip
Occupation
No. of Years Acquainted
First Name
Last Name
Telephone No
Address & Street
City
State
Zip
Occupation
No. of Years Acquainted
First Name
Last Name
Telephone No
Address & Street
City
State
Zip
Occupation
No. of Years Acquainted

Employment Process Items
Please Read Carefully, Initial Each Paragraph and Sign Below
- I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge even if I am employed, regardless of the time elapsed before discovery.
- I hereby authorize the company to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the references I have listed to disclose to the company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.
- I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and the company. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or the company, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the company’s designated representative.
Date
Applicant’s Signature

AUTHORIZATION FOR BACKGROUND CHECKS
I instruct and authorize Western Express Lending (the “Company”) to obtain a consumer report(s) (or background check
report(s)) on me, including any investigative consumer reports and any consumer credit reports.* I also agree that a copy of this form is valid like the signed original.

The consumer reporting agency (CRA) ADP Screening and Selection Services, Inc. (ADP SASS) will conduct the background

check and prepare the background check report for the Company. ADP SASS is located at 301 Remington Street, Fort Collins, CO, 80524,

and can be reached by phone at 800-367-5933, or at www.adpselect.com.

I understand that, as allowed by applicable law, the Company may rely on this authorization to order additional background

check reports, including investigative consumer reports and any consumer credit reports* (1) during my employment or time as a volunteer or independent contractor, as applicable, and (2) from any CRA other than ADP SASS without asking me for my authorization again. I understand the Company may order background check report(s) under my legal name and any other names I may have used.

I also instruct and authorize the following persons, agencies, and entities to disclose to ADP SASS and its agents all information about or concerning me, as allowed by law, 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; 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.

As allowed by law, such disclosures may contain the following information pertaining to me: credit history*; public records; a Social Security number verification; driving records; military service; credentials/certifications; worker’s compensation injuries; and verification of prior employment and education.

*I understand that I am instructing and authorizing the Company to obtain a consumer credit report only to the extent permitted by law. If I reside or anticipate being employed in New York City, I understand that I am not being asked to authorize a consumer credit report by signing this document.

By signing below, I understand that I am agreeing to the terms contained in this document.

If you live or work for the Company in California, Minnesota or Oklahoma: Check this box if you would like a free copy of your background check report:

BACKGROUND CHECK INFORMATION
The information requested below is collected solely for the purpose of aiding the Consumer Reporting Agency (CRA) in completing a background check on you.
First Name*
Middle Name
Last Name*
Suffix
Email Address:*
For Identification Purposes Only
Date of Birth*
Social Security Number
Driver’s License Number
State Issuing License
Enter Nickname(s) Used
Enter Any Other Names Used (including maiden names):
First Name
Middle Name
Last Name
First Name
Middle Name
Last Name
First Name
Middle Name
Last Name
Addresses Within The Past Seven Years (use a separate sheet as needed)
Present Street Address
City
State
Zip
Prior Street Address
Prior City
State
ZIP
From
To

Employment Application

Western Express Lending

Personal Information

Education, Training and Experience

School

High School

College/University

Vocational/ Business

EMPLOYMENT HISTORY/CERTIFICATION

Answer the following questions if you are applying for a LICENSED OR CERTIFIED position:

Employment History

List below all present and past employment starting with your most recent employer (last five years is sufficient). Account for all periods of unemployment. You must complete this section even if attaching a resume.

MILITARY HISTORY - REFERENCES

Employment Process Items

Please Read Carefully, Initial Each Paragraph and Sign Below

AUTHORIZATION FOR BACKGROUND CHECKS

If you live or work for the Company in California, Minnesota or Oklahoma: Check this box if you would like a free copy of your background check report:

BACKGROUND CHECK INFORMATION

For Identification Purposes Only