Name: Dixie Power
Telephone: +1

Employment Application

Thank you for you consideration to apply for Dixie Power. Please fill out the application as much as possible. You are welcome to resume your application at a later time if needed.

Step 1 of 4

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Education History
High School
High School
High School Address
What years did you attend high school?
Did you graduate high school?
- Yes
- No
College
College
College Address
What years did you attend college?
Did you graduate college?
- Yes
- No
Other Education
Any other form of Education?
Other form of Education Address
What years did you attend this other form of education?
Did you graduate from this other form of education?
- Yes
- No
Describe any other education or training
References
Please provide 3 references
Reference 1
Name*
Relationship
Occupation
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Reference 2
Name*
Relationship
Occupation
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Reference 3
Name*
Relationship
Occupation
Address
Street Address City State / Province / Region ZIP / Postal Code Country

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Employment History
Please provide 3 previous employers.
Employer 1
Employer Name*
Phone*
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Responsibilities
Job Title
Supervisor
Starting Wage/Salary
Ending Wage/Salary
Start Date
MM
DD
YYYY
Reason For Leaving
End Date*
MM
DD
YYYY
Current Employer
- Yes
- No
May we contact this employer?*
Employer 2
Employer Name*
Phone*
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Responsibilities
Job Title
Supervisor
Starting Wage/Salary
Ending Wage/Salary
Start Date
MM
DD
YYYY
Reason For Leaving
End Date*
MM
DD
YYYY
Current Employer
- Yes
- No
May we contact this employer?*
Employer 3
Employer Name*
Phone*
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Responsibilities
Job Title
Supervisor
Starting Wage/Salary
Ending Wage/Salary
Start Date
MM
DD
YYYY
Reason For Leaving
End Date*
MM
DD
YYYY
Current Employer
- Yes
- No
May we contact this employer?*
Military
Did you server in the military?
- Yes
- No
Branch
What dates did this service occur?
Rank at Discharge
Type of Discharge
If other than honorable discharge, explain

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Consent
Electronic Transaction*
ELECTRONIC SIGNATURE CONSENT

As part of the selection process at DIXIE POWER, the "Company," you will need to consent to a background check electronically. By typing your name, you are consenting to receive any communications (legally required or otherwise) and all changes to such communications electronically. In order to use the website, you must provide at your own expense an Internet connected device that is compatible with the minimum requirements outlined below. You also confirm that your device will meet these specifications and requirements and will permit you to access and retain the communications electronically each time you access and use the website.

System Requirements to Access Information

To receive and view an electronic copy of the Communications you must have the following equipment and software:

A personal computer or other device which is capable of accessing the Internet. Your access to this page verifies that your system/device meets these requirements.
An Internet web browser which is capable of supporting 128-bit SSL encrypted communications, JavaScript, and cookies. Your system or device must have 128-bit SSL encryption software. Your access to this page verifies that your browser and encryption software/device meet these requirements.

System Requirements to Retain Information

To retain a copy, you must either have a printer connected to your personal computer or other device or, alternatively, the ability to save a copy through use of printing service or software such as Adobe Acrobat®. If you would like to proceed using paper forms, please contact DIXIE POWER.

Withdrawal of Electronic Acceptance of Disclosures and Notices

You can also contact us to withdraw your consent to receive any future communications electronically, including if the system requirements described above change and you no longer possess the required system. If you withdraw your consent, we will terminate your use of the Western Reporting website and the services provided through Western Reporting website.

To ensure that a signature is unique and to safeguard you against unauthorized use of your name, your IP address (63.234.227.210) has been recorded and will be stored along with your electronic signature. Please note that if you wish to submit your Disclosure and Authorization Forms electronically, Western Reporting requires that you include your social security number or user identification. All of your information will be encrypted and transmitted via our secure website.

I understand that Western Reporting uses computer technology to ensure that my signed documents are not altered after submission. I agree to allow Western Reporting to validate my signed documents in this way.

I consent to transacting electronically, including receiving legally required notices electronically.
Fair Credit Summary of Rights*

I acknowledge receipt of the Summary of Your Rights Under the Fair Credit Reporting Act (FCRA) and certify that I have read and understand this document
Disclosure Regarding Background Investigation*
DISCLOSURE REGARDING BACKGROUND INVESTIGATION

[IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING ACKNOWLEDGMENT]

DIXIE POWER ("the Company") may obtain information about you for employment purposes from the following consumer reporting agency ("Agency"), Western Reporting, 8789 S HIGHLAND DR STE 300, SANDY, UT 84093, Phone: (801) 308-0005, Fax: (801) 308-0015, or another outside organization. Agency's privacy policy can be found at www.westernreporting.com.

Thus, you may be the subject of a "consumer report" and/or an "investigative consumer report" which may include information about your character, general reputation, personal characteristics, and/or mode of living, and which can involve personal interviews with sources such as your neighbors, friends, or associates. These reports may be obtained at any time after receipt of your authorization and, if you are hired, throughout your employment. These reports may include, but are not limited to, checks regarding your criminal history, social security trace, employment and education references, driving history, professional licenses and credentials. Credit history will be requested only in accordance with applicable law. These reports may contain information regarding your use of social media, and other publicly accessible information. Social media includes, but is not limited to, social networking websites (i.e., Facebook and others), professional networking websites (i.e., LinkedIn and others), blogs, and other online media.

You have the right, upon written request made within a reasonable time after receipt of this notice, to ask the Company to disclose the nature and scope of any investigative consumer report. You also may request a copy of that report from the Company. If anyone other than Agency furnishes an investigative consumer report, Company will provide relevant contact information within five business days of your request. An "investigative consumer report" is a background report that includes information from personal interviews (except in California, where that term includes background reports with or without personal interviews). Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your education and/or employment history conducted by Agency. The scope of this disclosure and authorization is all-encompassing, however, allowing Company to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and, if you are hired, throughout the course of your employment to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report.

Maine, Massachusetts, and New Jersey applicants or employees only: You have the right to inspect and promptly receive a copy of any investigative consumer report requested by Company by contacting the consumer reporting agency identified above directly.

Minnesota applicants or employees only: You have the right, upon written request to Agency, to receive a complete and accurate disclosure of the nature and scope of any consumer report. Agency must make this disclosure within five days of receipt of your request or of the Company's request for the report, whichever is later.

New York applicants or employees only: You have the right to request whether Company requested a consumer report and, if so, Company will give you the name and address of the report's provider if other than Agency.

California, Minnesota and Oklahoma applicants or employees only: Please check this box if you would like to receive from Agency a copy of any report furnished by Agency to the Company pursuant to your authorization below.

Washington applicants or employees only: The Company will provide the disclosure described above concerning its procurement of an investigative consumer report either five days after receiving your request or after requesting the investigative consumer report, whichever is later. You have the right to ask Company to provide you with a summary of your rights under the Washington Fair Credit Reporting Act.

I acknowledge receipt of this Disclosure and certify that I have read and understand this document
Signature
Acknowledgement and Authorization*
I agree to the Acknowledgement and Authorization
ACKNOWLEDGMENT AND AUTHORIZATION

[IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING ACKNOWLEDGMENT]

I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the procurement of "consumer reports" and/or "investigative consumer reports" at any time after receipt of this authorization and, if I am hired, throughout my employment. To this end, I hereby authorize, without reservation, 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 by Western Reporting, 8789 S HIGHLAND DR STE 300, SANDY, UT 84093, Phone: (801) 308-0005, Fax: (801) 308-0015, www.westernreporting.com, another outside organization acting on behalf of DIXIE POWER ("the Company"), and/or the Company itself. I agree that a facsimile ("fax"), electronic or photographic copy of this Authorization shall be as valid as the original.

I understand that by typing my name and the last four digits of my Social Security Number or User ID, and clicking on the "Next" button below, constitutes my electronic signature, dated as of when I click on the "Next" button, and that by doing so:
- I am authorizing Western Reporting to conduct the background check(s) described above
- I am consenting to use electronic means to sign this form and have read and understand the above disclosure
- I acknowledge I may request a hard copy of this Disclosure and Authorization form after agreeing to the background check electronically by calling Western Reporting at Phone: (801) 308-0005, Fax: (801) 308-0015.
Signature
ID/SSN (last 4):