Western Express Lending Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Last Name*First Name*Middle NamePresent AddressCityStateZipPermanent Address (if different from present address)CityStateZipCell Phone*Home PhoneSocial Security NumberPosition applying for:Regular full-time work?YesNoRegular part-time work?YesNoTemporary work, e.g., summer or holiday work?YesNoWhat 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?YesNoWould you be available to work overtime, if necessary?YesNoIf hired, on what date can you start work?Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Salary desired: Personal InformationHave you ever applied to or worked for Western Express Lending before?YesNoIf yes, when?DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Do you have any friends or relatives working for Western Express Lending?YesNoIf yes, state name(s) and relationship:Why are you applying for work at Western Express Lending?If hired, would you have a reliable means of transportation to and from work?YesNoAre you at least 18 years old? (If under 18, hire is subject to verification that you are of minimum legal age.)YesNoIf hired, can you present evidence of your U.S. citizenship or proof of your legal right to live and work in this country?YesNoAre you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation?YesNoIf no, describe the functions that cannot be performed(Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Hire may be subject to passing a medical examination, and to skill and agility tests.)Have you ever been convicted of a criminal offense (felony or serious misdemeanor)? (Convictions for marijuana-related offenses that are more than two years old need not be listed.)YesNoIf yes, state nature of the crime(s), when and where convicted and disposition of the case(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.) Are you currently employed?YesNoIf so, may we contact your current employer?YesNo Education, Training and Experience SchoolSchool NameAddressNo. of years CompletedDid you Graduate?YesNoDegree or DiplomaDegreeDiplomaHigh SchoolHigh School NameAddressCityStateZipCollege/UniversityCollege/University NameAddressCityStateZipNo. of years CompletedDid you Graduate?YesNoDegree or DiplomaDegreeDiplomaVocational/ BusinessVocational/ BusinessAddressCityStateZipNo. of years CompletedDid you Graduate?YesNoDegree or Diploma?DegreeDiplomaMany of our customers (clients) do not speak English. Do you speak, write or understand any foreign languages?YesNoIf yes, which languages(s)?Do you have any other experience, training, qualifications or skills which you feel make you especially suited for work at Western Express Lending?YesNoIf so, please explain: EMPLOYMENT HISTORY/CERTIFICATIONAnswer the following questions if you are applying for a LICENSED OR CERTIFIED position:Are you licensed/certified for the job applied for?YesNoName of license/certification:Issuing state:License/certification numberHas your license/certification ever been revoked or suspended?YesNoIf yes, state reason(s), date of revocation or suspension and date of reinstatement.Employment HistoryList 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 EmployerTelephone No.Type of BusinessYour Supervisor's NameAddress & StreetCityStateZipYour Position and DutiesReason for LeavingMay we contact this employer for a reference?YesNoName of EmployerTelephone No.Type of BusinessYour Supervisor's NameAddress & StreetCityStateZipDates of Employment: FromMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920ToMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Weekly Pay: StartingEndingYour Position and DutiesReason for LeavingMay we contact this employer for a reference?YesNo MILITARY HISTORY - REFERENCESHave you obtained any special skills or abilities as the result of service in the military?YesNoIf so, describe:ReferencesList below three persons not related to you who have knowledge of your work performance within the last three years.First NameLast NameTelephone NoAddress & StreetCityStateZipOccupationNo. of Years AcquaintedFirst NameLast NameTelephone NoAddress & StreetCityStateZipOccupationNo. of Years AcquaintedFirst NameLast NameTelephone NoAddress & StreetCityStateZipOccupationNo. of Years Acquainted Employment Process ItemsPlease 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. DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Applicant’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 NameLast Name*SuffixEmail Address:* For Identification Purposes OnlyDate of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Social Security NumberDriver’s License NumberState Issuing LicenseEnter Nickname(s) UsedEnter Any Other Names Used (including maiden names):First NameMiddle NameLast NameFirst NameMiddle NameLast NameFirst NameMiddle NameLast NameAddresses Within The Past Seven Years (use a separate sheet as needed)Present Street AddressCityStateZipPrior Street AddressPrior CityStateZIPFromMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920ToMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 This iframe contains the logic required to handle Ajax powered Gravity Forms.