EMPLOYEE CHECK LIST – PART-TIME/SEASONAL

Name:______________________________________ Supervisor:_____________________

New Hire / Rehire / Reactivate / Other ____________ Effective Date: _______________

Primary Program: ___________________________________

Additional Programs: (please check ALL that apply)

Department #:

ATTENTION EMPLOYEES: If you have changes to your direct deposit and/or tax withholdings please ask your Supervisor for the necessary forms.

Effective Date:_________________________________

Supervisor: ___________________________________

Reactivate: _______ Requires EPI and Justifacts

Rehire: ___________ Requires App and Full Packet

Checklist filled out: _____

Active Login Needed: Y / N Job: __________________

EMPLOYEE PERSONNEL INFORMATION (EPI)

First Name: _________________ Middle Name: ________________ Last Name: _____________________________

Social Security Number:__________________ Date of Birth:_____________ Phone Number(s): Home __________ Cell __________

Mailing Address City: State: Zip:

Physical Address: _________________________ City: ________________________ State: ______ Zip: ____________

E-mail: __________________________________________ Have you ever been previously employed by the City?_____

Gender:_____ Marital Status:_____ Are you a United States Citizen?__________ Are you a Veteran?_________

Primary Emergency Contact (Home, Work or Cell, circle the appopriate type)

Name: _____________________________________ Relationship to you: _________________

Primary Phone Number: ____________________ H – W – C Secondary Phone Number: _____________________ H – W – C

Secondary Emergency Contact (Home, Work or Cell, circle the appopriate type)

Name: ____________________________________ Relationship to you: ________________

Primary Phone Number: ____________________ H – W – C Secondary Phone Number: _____________________ H – W – C

Allergies or medications my supervisor should know about:________________________________________

To ensure your health and safety let your supervisor know of any doctor’s restrictions or medications that you are required or will be required to take while employed for a medical condition that would affect your performance on the job. (Example: inhalers or epi pens) Should you forget to bring an essential doctor prescribed medication to work, you may be sent home for the day. Employee is responsible for reporting changes in medical condition that would impact his/her ability and will be personally responsible for safeguarding required medication they are required to bring to work.

DRIVER INFORMATION

Do you currently hold a     Will you be driving for any

valid CO Driver’s License?*_______ reason as part of your job?________ Driver’s License Number:__________________

*If you do NOT currently have a CO license, please get a copy of it to HR once you obtain one.

State of Issuance: ______ Class: ___________ CDL? ______ Issue Date: ______________ Expiration Date: ______________

List any restrictions, if applicable: _______________________________________________________________________

Is your license suspended or invalid? ________ If yes, give the reason(s): __________________________________________

I have verified the above information and have indicated all changes as necessary:

__________________________________________ _______________

Signature           Date  

Faxed to Community:______________

PRE-PLACEMENT TEST

City of Grand Junction

LOCATION OF TEST:  Community Hospital, Center for Occupational and Industrial Health

       2004 North 12th Street

(Located across the street from the hospital. Sign says Therapy Works and Occupational Health.)

644-3700 (Occ Health) 644-3700 (Dr. Sofish) 644-3715 (FAX)

Hours: Monday - Friday 7:00 a.m. - 5:00 p.m.

(No walk-ins 1/2 hour prior to closing)

NAME: _____________________________________ DOB ___________ PHONE: ________________

Tests to be conducted (Check all that apply) POSITION TITLE: __________________________

 Urine Drug Screen  ¨  

Simple Physical    ¨

•  includes audio matrix booth

•  Includes lifting evaluation- floor to waist; ____ 50 lbs, ____ 100 lbs

DOT Physical  ¨

•  includes DOT drug screen

•  includes DOT paperwork required to receive CDL card

•  includes audio matrix booth

•  includes lifting evaluation- floor to waist; ____ 50 lbs, ____ 100 lbs

 Audio matrix booth  ¨  

Ishihara eye exam  ¨

(Color blind test)  

Hepatitis A    ¨

Hepatitis B    ¨

TB Test (PPD)  ¨

Medical Qual. for Respirator Use    ¨

Pulmonary Function Test (PFT)    ¨

Test Date: __________Test Time: ______________Drug results: Negative or Positive _________                         Date

NOTIFY OF RESULTS:  Nikki Koehler, Human Resources (970) 256-4015

       City of Grand Junction

       250 North 5^th Street

       Grand Junction, CO 81501

       CONFIDENTIAL FAX: (970) 256-4007

Supervisor Name: ______________________________________ Phone: __________________________

Date Supervisor Notified: ___________________ via (Circle One) Phone E-Mail VM Left

Times candidate is available for drug/physical: ________________________________________________

Authorization to Conduct Employment Background Investigation

I hereby authorize Justifacts Credential Verification, Inc, an Agent for the CITY OF GRAND JUNCTION to ascertain information regarding my background to determine any and all information of concern to my record and I release employers and persons named in my application from all liability for any damages on account of his/her furnishing said information. I understand that this form indicates that a background search will be conducted and that this is my notification of that intent. I understand that the purpose of this background investigation is to determine my suitability for employment and may elicit information on my character, general reputation, personal characteristics and mode of living. Additionally, you are hereby authorized to make any investigation of my personal history, educational background, military record, motor vehicle records, criminal records, credit history and workers compensation records through an investigative agency or bureau of your choice. I authorize the release of this information by the appropriate agencies to the investigating service. I understand that my consent will apply throughout my employment, unless I revoke or cancel my consent by sending a signed letter or statement to the Company at any time, stating that I revoke my consent and no longer allow the Company to obtain consumer or investigative consumer reports about me.

  PLEASE PRINT CLEARLY

FULL NAME:                          

OTHER NAMES USED/MAIDEN NAME/DATES:                    

CURRENT

ADDRESS:                  PHONE:    

LIST ALL ADDRESSES FOR PAST 7 YEARS:

                    Dates:        

                    Dates:        

EMAIL ADDRESS: __________________________________

SOCIAL SECURITY #           DATE OF BIRTH:          

DRIVER’S LICENSE #               STATE ISSUED:        

*** MAY WE CONTACT YOUR CURRENT EMPLOYER? YES _______ NO    

*** HAVE YOU EVER BEEN CONVICTED OF A CRIME? YES _______ NO  

If yes, please explain:                                  

Note: No applicant will be denied employment solely on the grounds of conviction of a crime. The nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense to the position will be considered.

Notice to California Applicants – By signing below, you acknowledge receiving the “Notice to California Residents”. You may omit minor traffic offenses, any convictions which have been sealed, expunged or statutorily eradicated, convictions more than two years old for the following marijuana related offenses: HS11357b&c, HS11360c, HS11364, HS11365, HS11550, and misdemeanors for which probation was completed and the case was judicially dismissed.

Notice to Massachusetts Applicants: You may omit a first conviction for any of the following misdemeanors: drunkenness, simple assault, speeding, minor traffic violations, affray, or disturbance of the peace, or any conviction of a misdemeanor where the date of such conviction or the completion of any period of incarceration resulting there from, whichever date is later, occurred five or more years prior to the date of this application for employment, unless you have been convicted of any offense within five years immediately preceding the date of this application for employment.

Notice to New York Applicants – By signing below, you acknowledge receiving a copy of Article 23-A of the New York Correction Law, governing the licensure and employment of persons previously convicted of one or more criminal charges.

SIGNATURE:             DATE:      

California, Minnesota & Oklahoma Applicants Only: Please check this box if you would like a copy of the background check mailed to you. Minnesota and Oklahoma applicants will receive a copy direct from Justifacts or its designee. California applicants may receive a copy from either the prospective employer or Justifacts.

NOTICE:  Under federal law, you have the right to request disclosure of the nature and scope of our investigation by providing us with a written request within 60 days of our background investigation.

Subscriber certifies that consumer credit information, consumer reports, as defined by the Fair Credit Reporting Act, 15 U.S.C. 1681 at seq. (“FCRA”), will be ordered only when intended to be used as a factor in establishing a consumer’s eligibility for employment and that consumer credit information will be used for no other purposes. It is recognized and understood that the FCRA provides that anyone “who knowingly and willfully obtains information on a consumer from a consumer reporting agency” (such as Justifacts) “under false pretenses shall be fined not more than $2,500 or imprisoned not more than two years or both.”