Sanaajel Form – Fill Out and Use This PDF

APPLICATION FOR EMPLOYMENT

WORK HISTORY

Begin with present or most recent position first. List work experience for PAST 10 YEARS. Attach resume, if necessary. Account for all periods of time including military service (provide DD214) and any periods of unemployment. If self-employed, provide firm name and 1099 and/or tax records.

Sanjel (USA) Inc.

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APPLICATION FOR EMPLOYMENT

MOTOR VEHICLE RECORDS HISTORY

To CMV applicant: The information below is required by the Department of Transportation (DOT) regulations

section 391.23.

List all violations of motor vehicle and/or traffic laws and ordinances within the past 5 years (i.e. speeding, reckless driving, DUI, etc): _________________________________________________________________________________

_______________________________________________________________________________________________

ACCIDENT RECORD FOR THE PAST 3 YEARS (ATTACH SHEET IF MORE SPACE IS NEEDED)

LIST ALL DRIVER LICENSES AND/OR PERMITS HELD WITHIN LAST 5 YEARS

Sanjel (USA) Inc.

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POST- OFFER / PRE - PLACEMENT TESTING POLICY

POLICY:

It is the policy of Sanjel (USA) Inc. (“Sanjel USA” or the “Company”) to conduct post-offer/pre-employment examinations. Post-offer/Pre-placement examinations are successful tools utilized to evaluate whether a candidate or prospective employee is able to perform the job with or without reasonable accommodation and to create a safer working environment by identifying any significant risk to the health and safety of the prospective employee or others that cannot be resolved by reasonable accommodations.

Sanjel has implemented the WorkSTEPS® evaluation program for all prospective employees in designated job categories as set forth below. The WorkSTEPS®program has been in effect since 1986, has one of the largest normative databases in the United States, and has proven its success by creating safety in the workplace. Recognizing that every job and every employee are different, the tests are utilized to determine whether or not the employee can safely perform job duties.

When necessary, to enable an otherwise qualified candidate with a disability to participate in testing, Sanjel will provide reasonable accommodations provided such accommodations do not cause an undue hardship. Prospective employees, who believe they need an accommodation to participate in the testing program, must request such accommodations. To minimize or avoid delays in testing, Sanjel asks prospective employees to advise the Company of the need for any accommodation as soon as possible after receiving a conditional offer of employment.

All applicants for employment in any field or shop position who receive a conditional offer of employment will be required to successfully complete a functional employment test.

Below is the process that will be followed:

Upon receiving conditional offers of employment, candidates will be given written job descriptions and additional written information regarding the post-offer/pre-placement functional employment test. After carefully reviewing this information and/or consulting with their personal physicians, candidates must complete a release authorizing Sanjel, WorkSTEPS®, and the licensed WorkSTEPS® testing facility to conduct the post-offer functional employment tests. Requests for accommodations should be noted on the release. Depending on the nature of the accommodation sought, further discussions and/or medical documentation may be needed to identify an appropriate accommodation. Testing will be delayed until the interactive process aimed at identifying appropriate and necessary reasonable accommodations is completed.

Once Sanjel receives a fully completed release and any requests for reasonable accommodation are resolved, Sanjel will schedule candidates for the post-offer/pre-placement functional employment test.

Upon reporting to the licensed WorkSTEPS® testing facility, candidates will be examined by a licensed occupational or physical therapist and their staff.

Because Sanjel seeks to make employment decisions based on the best available objective medical evidence, candidates who receive a “not capable” result or who are unable to complete the test should provide Sanjel with any additional information they believe the company should consider in evaluating the conditional offer of employment.

If it is determined that the candidate is unable to perform the essential job functions with or without a reasonable accommodation or the candidate would pose a direct threat to the health and safety of the candidate or others, which threat cannot be reduced to an acceptable level with a reasonable accommodation, Sanjel will withdraw the conditional offer of employment.

Candidates, who successfully complete the post-offer/pre-placement functional employment test, will be contacted by human resources or other authorized representative about employment.

POST- OFFER / PRE - PLACEMENT TESTING POLICY

Additional Points:

The costs of post-offer/pre-placement employment test procedures are paid by Sanjel. Medical information collected in connection with such tests will be maintained as confidential in accordance with requirements of applicable law, including the Americans with Disabilities Act (ADA), as amended, and the information collected will not be used for any purpose inconsistent with the ADA, as amended, or other applicable law.

The Company is an equal opportunity employer and does not discriminate against individuals on the basis of race, religion, color, sex, age, national origin, mental or physical disability, veteran status, or other conditions or identifications against which discrimination is prohibited by federal, state or local law.

Acknowledgment:

I have read the above policy and understand that if offered employment it will be conditioned on the successful completion of a post-offer/pre-placement functional employment examination. I hereby agree to comply with the above procedure and request that my application for employment be processed pursuant to this policy.

In all states recognizing “at will” employment, employees of Sanjel (USA), Inc. (“Sanjel USA”) are employed “at will.” Employment is not for any definite term, and the employment relationship may be terminated at any time and for any lawful reason.

Sanjel USA may publish various policies, procedures and handbooks from time to time. Sanjel USA employees are expected to abide by the requirements expressed in those documents. However, nothing in any policies, procedures or handbooks constitutes a contract of employment with Sanjel USA. Sanjel USA may modify, amend or terminate such policies, procedures and handbooks from time to time in its sole discretion.

Para informacion en espanol, viste www.ftc.gov/credit o escribe a la FTC Consumer Response Center, Room 130-A 600 Pennsylvania Ave NW, Washington, D.C. 20580.

A Summary of Your Rights Under the Fair Credit Reporting Act

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of the consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to www.ftc.gov/credit or write to: Consumer Response Center, Room 130-A, Federal Trade Commission, 600 Pennsylvania Ave. NW, Washington, D.C. 20580.

•You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment – or to take adverse action against you – must tell you, and must give you the name, address, and phone number of the agency that provided the information.

•You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your “file disclosure”). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free disclosure if:

O a person has taken adverse action against you because of information in your credit report; O you are the victim of identify theft and place a fraud alert in your file;

O your file contains inaccurate information as a result of fraud; O you are on public assistant;

O you are unemployed but expect to apply for employment within 60 days.

In addition, by September 2005 all consumers will be entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.ftc.gov/credit for additional information.

•You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.

•You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See www.ftc.gov/credit for an explanation of dispute procedures.

•Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.

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•Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.

•Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need – usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access.

•You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to www.ftc.gov/credit.

•You may limit “prescreened” offers of credit and insurance you get based on information in your credit report. Unsolicited “prescreened” offers for credit and insurance must include a toll-free number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at 1-888-5- OPTOUT (1-888-567-8688).

•You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.

•Identity theft victims and active duty military personnel have additional rights. For more information, visit www.ftc.gov/credit.

States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. Federal enforcers are:

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