Employment Application

Kaw Nation

Employment Application

698 Grandview Drive, Kaw City, OK 74641

*P.O. Box 50, Kaw City, OK 74641* Phone 580-269-2552

Email: HRClerk@KawNation.gov *Website: WWW.KawNation.gov

Answer each question fully and accurately. NO action can be taken on this application until you have answered all

questions. PLEASE PRINT, except for signature on application:

Job Applying For: Today's Date:

Are you seeking: Full-Time [_] Part-Time [[_] _ Internship [1] Other:

When are you available to start? What is your desired salary?

PERSONAL INFORMATION:

Last Name: First Name: Middle Name:

Other names you have used in the past:

Address: City/State/Zip:

Date of Birth: Social Security #:

Phone #: Email Address:

Are you 18 years orolder?__—s—s Yes ____ No *If No, can you provide a work permit?__ Yes ___ No

Do you claim Indian Preference? __—ss—s *Yes ____——s Noo

Tribal Affiliation: *Please attach Certificate Degree of Indian Blood (CDIB)

Do you have a valid Driver's license? Yes___ = No__If Yes, Please provide:

License Number: State: Type: Restrictions? Yes__ No.

If so,please explain restrictions:

Have you had your driver's license suspended or revoked in the last 5 years? Yes [__] No [_]

List all states that you have lived in, including where you were born:

Would you be insurable under the Kaw Nation's insurance carrier? Yes [_] No [_]

Have you served in the Military or National Guard? “Yes []No O

If yes, which branch? Ifyes, you must attach the DD-214 Form.

Have you been convicted of a felony in the past 10 years Yes[_] No |

Have you EVER been convicted of any law violation? Include any plea of “guilty” or “no contest.”

Exclude minor traffic violations Yes []No[_]

Are you a registered sex offender? Yes | No C] /

Would you be willing to submit to an Alcohol and Drug Testing? Yes [] No [7]

Would you be willing to submit a release for permission to conduct a background check? Yes] No[]

Have you ever applied for employment here? Yes({]No C)

Have you ever been employed anywhere within Kaw Nation? Yes___ No___

If yes, When were you employed? Where were you employed?

If hired, can you furnish proof you are eligible to work in the U.S.? Yes___ No___

Do you have any family relations currently working at Kaw Nation ? *Yes____- No___

* If yes, Who?,

Do you have any family relations working for another Tribal Afflilation? Yes__. No__

SKILLS AND QUALIFICATIONS:

Summarize any special training skills, machine or equipment, licenses and/or certifications that may qualify you being able

to perform job related functions in the position for which you are applying.

EDUCATIONAL BACKGROUND: List the schools attended starting with the most recent:

Schoo! and Location

Dates Attended

Course of Study

Degree/Certificate

Did you Graduate?

Do you posse a high school diptoma? Yes. *No.

*If No,do you posse a general education diploma (GED)? Yes. No

What is the highest level of education completed?

Have you attended school under any other names? Yes__.- No__

If yes, please list names:

Employment History:

List names of employers in consecutive order with present or last employer listed first. Account for all periods of time

including military service and any periods of unemployment in the last 10 years. If self-employed, give firm name and

supply business references. NOTE: A job offer is contingent upon verification of references and drug screen and

background check. (Please do not write “see resume’).

Employer:

Address:

IPhone:

From: To:

JobTitle:

Supervisor:

Ending Salary: $

May we contract? Yes No

Reason for Leaving:

Job Duties:

Employer: Address: IPhone:

From: To: JobTitle: Supervisor: Ending Salary: $

Reason for Leaving:

May we contract? Yes No

Job Duties:

Employer: Address: Phone:

From: To: JobTitle: Supervisor: Endig Salary:$

May we contact? Yes No Reason for Leaving:

Job Duties:

Employment History Continued:

Employer Address: Phone:

From: To: Job Title: Supervisor Ending Salary:$

May we contact? Yes No /Reason for Leaving:

Job duties:

Employer: Address: Phone:

From: To: Job Title: Supervisor: Ending Salary:$

May we contact? Yes No |Reason for Leaving:

Job duties:

Are you presently employed? Yes___ No__

If yes, may we contact them for reference? Yes___ No___

If yes, whom do we.contact?

Name of Contact: Job Title:

Phone Number:

Have you ever been fired from a job or asked to resign? Yes__ No___

If yes,please explain:

REFERENCES: Give at least three (3) individuals NOT related to you but whom you have known at least one year.

Name of Reference

Relation

Title

Company

Phone Number |Address

| certify that the facts contained in this application are true and complete to the best of my knowledge and understand

that if employed, falsified statements on this application shall be grounds for dismissal. | authorize an investigation of all

statements contained herein and the references listed above to give you any and all information concerning my previous

employment and any pertinent information they may have, personal or otherwise and release all parties from all liability

for any damage that may result from furnishing same to you. | understand that this application, verbal statements by

management, or subsequent employment does not create, express or implied contract of employment nor guarantee

employment for any define period of time. If employed, | understand that I have been hired at the will of Kaw Nation and

my employment maybe terminated at any time, with or without reason and with or without notice.

Applicant Full Legal Name (Print).

Applicant Signature:

Date:

Page 3

ACKNOWLEDGEMENT

The Kaw Nation adopts the provisions of the Indian Self Determination & Education Assistance Act PL 93-638 as amended. In

selection for employment, preference will be given to enrolled members of federally recognized Nations, providing other

qualifying factors prove the enrolled member equal in merit to other applicants.

| certify answers given on this application are true and complete to the best of my knowledge. In the event of employment, |

understand false or misleading information given in my application or interview(s) may result in termination of employment

regardless of length of employment, or cancellation of the job offer without notice. | understand | am required to abide by all

rules, regulations, and laws of Kaw Nation.

The applicant does hereby authorize The Kaw Nation to seek employment verification, information, or records from all former

and current employers listed on this application. | hereby give my permission to Kaw Nation to investigate all statements

given in this application or during interview(s), and | release from liability any person, company, agency, or corporation

collecting or supplying such information to Kaw Nation and its employees.

| understand that Kaw Nation will conduct criminal background check and sex offender registry search.

Fingerprint check will be required for anyone wor ing with children and other sensitive areas of Kaw Nation.

| understand if | am employed by Kaw Nation in a position where | will be driving a Kaw Nation vehicle on a regular basis;any

offer of employment I receive will be contingent on Kaw Nation verifying | have an acceptable driving record and a valid

Driver's license. | authorize the Kaw Nation or its designated representative's) to obtain information regarding my driving

record in any state at any time while | am employed by (or seeking employment with) Kaw Nation. In the event my report

indicates | am a high risk.kHigh Risk Driver as defined in the glossary of the Fleet Safety Program, | understand | may be

subject to dismissal.

I further understand offers of employment are contingent upon passing a criminal background checkk, and in some

designated positions accreditation through the Bureau of Indian Affairs (BIA). | further understand | will be required to pass a

post offer of employment drug screen and/or medical review.

| understand acceptance of an offer of employment does not create a contractual obligation upon Kaw Nation to continue

to employ me in the future. | acknowledge Kaw Nation is an “at-will” employer.

| understand that acceptance of this application does not necessarily guarantee employment or constitute an employment

contract between Kaw Nation and myself.

I] have read and understand the above statement.

Print Legal Full Name:

Signature of Applicant:

Date of Application:

For Human Resources Use Only:

Date Received in Human Resources:

For Position:

Received by: Interview Scheduled: Yes

Date of Interview:

FCRA NOTICE — BACKGROUND INVESTIGATION

In connection with your employment application with Kaw Nation this notice is intended to inform you

that an investigative consumer report will be obtained on you from a consumer reporting agency for

employment purposes. These purposes may include for hiring, retention, promotion or reassignment. The

report may contain information about your character, general reputation, personal characteristics and

mode of living, which may be based on personal interviews with sources such as your neighbors, friends

or associates. The report may also contain information about you relating to your criminal information or

history, credit history, driving and/or motor vehicle records, verification of your education or employment

history, or other background checks.

You have the right, upon written request made within a reasonable time after the receipt of this notice, to

request disclosure of the nature and scope of any investigative consumer report to the Company and our

background screening provider, National Crime Search, LLC, 3452 E. Joyce Blvd., Fayetteville, AR 72703

(888-527-3282). For information about National Crime Search, LLC’s privacy practices, see

Www.nationalcrimesearch.com.

p. 1 of 1

Revised Oct 2023

AUTHORIZATION FOR BACKGROUND INVESTIGATION

By signing below you authorize the obtaining of investigative consumer reports by the Kaw

Nation at any ‘time after receipt of this authorization. To this end, you authorize any law

enforcement agency, administrator, state or federal agency, institution, school or university

(public or private), information service bureau, employer, or insurance company to furnish any

and all background information requested about you by National Crime Search, LLC and/or Kaw

Nation.

You understand that the scope of your authorization is not limited to the present and, if you are

hired, will continue throughout the course of your employment and allow the Kaw Nation to

conduct future screenings for retention, promotion or reassignment, as permitted by law and

unless revoked by you in writing.

Print Full Legal Name:

Other or Former

Names (please print):

Date of Birth*:

Social Security

Number:

Address:

City:

County:

State:

Zip Code:

Driver’s License

number:

State License issued:

Name on License (if

different than legal

name:

Email Address:

Phone Number:

Signature:

Parent/Guardian

signature **:

Date:

*This information will be used for background screening purposes only and no other purpose.

**If the applicant is under 18 years old, both the applicant and a parent/guardian must sign the form.

Revised Oct 2023 ~

STATE LAW NOTICES AND DISCLOSURES —- BACKGROUND INVESTIGATION

The following disclosures are being provided pursuant to state law.

MINNESOTA and OKLAHOMA: If you are a resident of Minnesota or Oklahoma, or applying

for employment in one of these states, please check the box if you would like to receive a copy

of your consumer report, free of charge, if one is obtained by Kaw Nation.

Check box to receive report 0

MINNESOTA: If you are a Minnesota resident or applying for employment at a location within

Minnesota, you have the right to submit a written request to National Crime Search, LLC | 3452 E

Joyce Blvd, Fayetteville, AR 72703 | (888-527-3282) for a complete and accurate disclosure of

the nature and scope of any consumer report the Company ordered about you. The consumer

reporting agency must provide you with this disclosure within five days after its receipt of your

request or the report was requested by the Company, whichever date is later.

NEW JERSEY: If you are a New Jersey resident or applying for employment at a location within

New Jersey, you acknowledge receipt of the New Jersey Fair Credit Reporting Act provisions.

NEW YORK: If you are a New York resident or applying for employment at a location within

New York, you have the right to inspect and receive a copy of any investigative consumer report

requested by the Company by contacting National Crime Search, LLC | 3452 E Joyce Blvd,

Fayetteville, AR 72703 Phone: (888-527-3282).

NEW YORK: If you are a New York resident or applying for employment at a location within

New York, you acknowledge receipt of a copy of Article 23-A of the New York Correction Law.

RHODE ISLAND: If you are a resident of Rhode Island or applying for employment at a location

within Rhode Island, the Company may request a credit report from a consumer reporting agency

in connection with your application for employment.

VERMONT: If you are a Vermont resident or applying for employment at a location within

Vermont, you acknowledge receipt of the NOTICE - BACKGROUND INVESTIGATION AND

USE OF CREDIT INFORMATION.!

WASHINGTON STATE: If you are a Washington resident or applying for employment at a

location within Washington State, you have the right to request from National Crime Search, LLC

| 3452 E Joyce Blvd, Fayetteville, AR 72703 | (888-527-3282) a written summary of your rights

and remedies under the Washington Fair Credit Reporting Act.

‘Pursuant to Vermont law, employers requesting a credit report must provide job applicants/employees with a notice

identifying the specific basis under 21 V.S.A. § 495i for use of the report.

Para informacion en espaitl, visite www.consumerfinance.gov/learnmore o escribe ala

Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20352.

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 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 FCRA. For more information, including

information about additional rights, go to www.consumerfinance.gov/learnmore or write

to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

e 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 another adverse action against you — must tell you,

and must give you the name, address, and phone number of the agency that provided the

information.

e 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 file disclosure if:

© aperson has taken adverse action against you because of information in your

credit report;

you are the victim of identity theft and place a fraud alert in your file;

your file contains inaccurate information as a result of fraud;

you are on public assistance;

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

o000

In addition, all consumers are entitled to one free disclosure every 12 months upon

request from each nationwide credit bureau and from nationwide specialty consumer

reporting agencies. See www.consumerfinance.gov/learnmore for additional

information.

e 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.

e 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.consumerfinance.gov/learnmore 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.

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.consumerfinance.gov/learnmore.

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 phone number you can call if you choose to remove

your name and address form 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).

The following FCRA right applies with respect to nationwide consumer reporting

agencies:

CONSUMERS HAVE THE RIGHT TO OBTAIN A SECURITY FREEZE

You have a right to place a “security freeze” on your credit report, which will

prohibit a consumer reporting agency from releasing information in your credit

report without your express authorization. The security freeze is designed to prevent

credit, loans, and services from being approved in your name without your consent.

However, you should be aware that using a security freeze to take control over who gets

access to the personal and financial information in your credit report may delay, interfere

with, or prohibit the timely approval of any subsequent request or application you make

regarding a new loan, credit, mortgage, or any other account involving the extension of

credit.

As an alternative to a security freeze, you have the right to place an initial or extended

fraud alert on your credit file at no cost. An initial fraud alert is a 1-year alert that is

placed on a consumer’s credit file. Upon seeing a fraud alert display on a consumer’s

credit file, a business is required to take steps to verify the consumer’s identity before

extending new credit. If you are a victim of identity theft, you are entitled to an extended

fraud alert, which is a fraud alert lasting 7 years.

A security freeze does not apply to a person or entity, or its affiliates, or collection

agencies acting on behalf of the person or entity, with which you have an existing

account that requests information in your credit report for the purposes of reviewing or

collecting the account. Reviewing the account includes activities related to account

maintenance, monitoring, credit line increases, and account upgrades and enhancements.

e 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.

e Identity theft victims and active duty military personnel have additional rights. For

more information, visit www.consumerfinance.gov/learnmore.

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. For

information about your federal rights, contact:

TYPE OF BUSINESS: CONTACT:

1.a. Banks, savings associations, and credit unions with total a. Consumer Financial Protection Bureau

assets of over $10 billion and their affiliates 1700 G Street, N.W.

Washington, DC 20552

b. Such affiliates that are not banks, savings associations, or

credit unions also should list, in addition to the CFPB:

b. Federal Trade Commission

Consumer Response Center

600 Pennsylvania Avenue, N.W.

Washington, DC 20580

(877) 382-4357

2. To the extent not included in item 1 above:

a. National banks, federal savings associations, and federal

branches and federal agencies of foreign banks

b. State member banks, branches and agencies of foreign banks

(other than federal branches, federal agencies, and Insured State

Branches of Foreign Banks), commercial lending companies

owned or controlled by foreign banks, and organizations

operating under section 25 or 25A of the Federal Reserve Act.

ec, Nonmember Insured Banks, Insured State Branches of

Foreign Banks, and insured state savings associations

d. Federal Credit Unions

a. Office of the Comptroller of the Currency

Customer Assistance Group

P.O. Box 53570

Houston, TX 77052

b. Federal Reserve Consumer Help Center

P.O. Box 1200

Minneapolis, MN 55480

c. Division of Depositor and Consumer Protection

National Center for Consumer and Depositor Assistance

Federal Deposit Insurance Corporation

1100 Walnut Street, Box #11

Kansas City, MO 64106

d. National Credit Union Administration

Office of Consumer Financial Protection

1775 Duke Street

Alexandria, VA 22314

3. Air carriers

Assistant General Counsel for Office of Aviation Protection

Department of Transportation

1200 New Jersey Avenue, SE

Washington, DC 20590

4. Creditors Subject to the Surface Transportation Board

Office of Public Assistance, Governmental Affairs, and

Compliance

Surface Transportation Board

395 E Street, SW

Washington, DC 20423

5. Creditors Subject to the Packers and Stockyards Act, 1921

Nearest Packers and Stockyards Administration area supervisor

6. Small Business Investment Companies

Associate Administrator, Office of Capital Access

United States Small Business Administration

409 Third Street, SW, Suite 8200

Washington, DC 20416

7. Brokers and Dealers Securities and Exchange Commission

100 F Street, NE

Washington, DC 20549

8. Federal Land Banks, Federal Land Bank Associations, Farm Credit Administration

Federal! Intermediate Credit Banks, and Production Credit

Associations

1501 Farm Credit Drive

McLean, VA 22102-5090

9. Retailers, Finance Companies, and All Other Creditors Not

Listed Above

Federal Trade Commission

Consumer Response Center

600 Pennsylvania Avenue, NW

Washington, DC 20580

(877) 382-4357