PERSONAL DATA

Legal Social Security Number (Optional)

Name
First Middle Last
Home Telephone #
Current
Address Cell Telephone #
Street City State Zip

Position Applied For & Desired Wage Email

GENERAL INFORMATION

Are you age 18 or over? Yes No Are you a U.S. Citizen ? Yes No
Do you have a legal right to work and remain in the U.S.? Yes No
Note: Individuals with work authorization based on non-immigrant visa status should advise type of visa when submitting
application.

Have you ever been discharged from any employment or asked to resign? Yes No

If Yes, please explain.

EDUCATION/TRAINING/QUALIFICATIONS

Type of Name and City/State Highest Graduated? Month and year Diploma/Degree
Institution Location Year Completed (Yes or No) of Graduation
High School
College
Graduate School
Business, Trade,
Other
Certifications

Additional Notes:

1
www.1stchoicegov.com
 PREVIOUS WORK EXPEREINCE

Start with present or most recent employer. Please give accurate, complete full-time and part-time employment. Include any job-related military service and volunteer
activities. You may exclude organizations that indicate race, color, religion, gender, national origin, disabilities, or other protected status. Additional pages may be used
if needed. DO NOT WRITE “SEE RESUME.”

Present or Last Company Name Telephone

Address Dates of Employment

From: To:

Job Title Supervisor’s Name & Number Rate of Pay

Briefly Describe your Duties Reason for Leaving

Company Name Telephone

Address Dates of Employment

From: To:

Job Title Supervisor’s Name & Number Rate of Pay

Briefly Describe your Duties Reason for Leaving

Company Name Telephone

Address Dates of Employment

From: To:

Job Title Supervisor’s Name & Number Rate of Pay

Briefly Describe your Duties Reason for Leaving

Company Name Telephone

Address Dates of Employment

From: To:
Job Title Supervisor’s Name & Number Rate of Pay

Briefly Describe your Duties Reason for Leaving

We may contact the preceding list of employers unless you indicate those
you do not want us to contact.

2
www.1stchoicegov.com
 3 PROFESSIONAL REFERENCES (DIRECT SUPERVISORS ONLY)

Name And Title Phone Number Email Relationship

Do Not Contact: Reason

APPLICANT ACKNOWLEDGEMENT AND AUTHORIZATION

Please read carefully before signing.

I certify that all answers given by me are true, accurate and complete; I understand that the falsification,
misrepresentation or omission of fact on this application (or any other accompanying or required documents) will be
cause for denial of employment or immediate termination of employment, regardless of when or how discovered.

I authorize the investigation of all statements and information contained in this application. I release from all liability anyone
supplying such information and I also release the employer from all liability that might result from making an investigation.

If hired, I agree to conform to all of 1st Choice, LLC’s policies and procedures, and understand that, if employed, my employment is at-will and may be
terminated with or without cause, and with or without notice, at any time, at the option of either the company or me, I further understand that no
representation, whether oral or written by any representative or agent of the Company, at any time, can constitute a contract of employment. No
representative or agent of the company has the authority to enter into any agreement for employment for any specified period of time or to make any
change in any policy, procedure, benefit or other term or condition of employment other than in a document signed by the President & CEO, or to make
any agreement contrary to the foregoing.

I herby authorize any and all schools, former employers, references, courts and any others who have information about me to provide such information
to 1st Choice, LLC and/or any of its representatives, agents or vendors and I release all parties involved from any and all liability for any and all damage
that may result from providing such information.
By signing below I acknowledge that I have read, understood and agree to the above statements.

Applicant Signature ________________________________________________ Date ________________________

1st Choice, LLC is proud to be an equal opportunity employer. All qualified applicants will receive
consideration without regard to race, color, religion, gender, national origin, age, disability, veteran status or any other status protected by law.

3
www.1stchoicegov.com
 Authorization

Authorization: By signing below, you authorize: (a) HireRight/Orange Tree to request information about you from
any public or private information source;(b) anyone to provide information about you to HireRight/Orange Tree; (c)
HireRight/Orange Tree to provide us 1st Choice one or more reports based on that information; and(d) us to share
those reports with others for legitimate business purposes related to your employment. HireRight/Orange Tree
may investigate your education, work history, professional licenses and credentials, references, address history,
social security number validity, right to work, criminal record, lawsuits, driving record, credit history, and any other
information with public or private information sources. You acknowledge that a fax, image, or copy of this
authorization is as valid as the original. You make this authorization to be valid for as long as you are an applicant
or employee with us.

The Consumer Financial Protection Bureau's "Summary of Your Rights under the Fair Credit Reporting Act" is
attached to this authorization. If you are a New York applicant, a copy of New York's law on the use of criminal
records is attached. By signing below, you acknowledge receipt of these documents.

Personal Information: Please print the information requested below to identify yourself for HireRight/Orange Tree.
Printed name:
First Middle( □ none) Last
Other names used:
Current and former addresses:
current
from Mo/Yr to Mo/Yr Street City, State & Zip

from Mo/Yr to Mo/Yr Street City, State & Zip

from Mo/Yr to Mo/Yr Street City, State & Zip

Some government agencies and other information sources require the following information
when checking for records. HireRight/Orange Tree will not use it for any other purposes.

Date of birth Social security number

Driver's license number & state Name as it appears on license

Report Copy: If you are applying for a job or live in California, Minnesota, or Oklahoma, you may request
a copy of the report by checking this box: □.

Signature Date
 Disclosure

We, 1st Choice, will obtain one or more consumer reports or investigative consumer reports (or both)
about you for employment purposes. These purposes may include hiring, contract, assignment, promo­
tion, re-assignment, and termination. The reports will include information about your character, general
reputation, personal characteristics, and mode of living.

To prepare the reports, HireRight/Orange Tree may investigate your education, work history,
professional licenses and cre­dentials, references, address history, social security number validity, right
to work, criminal record, law­suits, driving record, credit history, and any other information with public
or private information sources.

You may obtain a copy of any report that HireRight/Orange Tree provides and HireRight/Orange Tree's
files about you (in person, by mail, or by phone) by providing identification to HireRight/Orange Tree. If
you do, HireRight/Orange Tree will provide you help to understand the files, including trained personnel
and an explanation of any codes. Another person may accompany you by providing identification.

If HireRight/Orange Tree obtains any information by interview, you have the right to obtain a complete
and accurate disclo­sure of the scope and nature of the investigation performed.

Please sign below to acknowledge your receipt of this disclosure.

Signature Date

Printed Name
 Employment Eligibility Verification USCIS
Form I-9
Department of Homeland Security OMB No.1615-0047
U.S. Citizenship and Immigration Services Expires 05/31/2027

START HERE: Employers must ensure the form instructions are available to employees when completing this form. Employers are liable for
failing to comply with the requirements for completing this form. See below and the Instructions.
ANTI-DISCRIMINATION NOTICE: All employees can choose which acceptable documentation to present for Form I-9. Employers cannot ask
employees for documentation to verify information in Section 1, or specify which acceptable documentation employees must present for Section 2 or
Supplement B, Reverification and Rehire. Treating employees differently based on their citizenship, immigration status, or national origin may be illegal.

Section 1. Employee Information and Attestation: Employees must complete and sign Section 1 of Form I-9 no later than the first
day of employment, but not before accepting a job offer.
Last Name (Family Name) First Name (Given Name) Middle Initial (if any) Other Last Names Used (if any)

Address (Street Number and Name) Apt. Number (if any) City or Town State ZIP Code

Date of Birth (mm/dd/yyyy) U.S. Social Security Number Employee's Email Address Employee's Telephone Number

I am aware that federal law Check one of the following boxes to attest to your citizenship or immigration status (See page 2 and 3 of the instructions.):
provides for imprisonment and/or
1. A citizen of the United States
fines for false statements, or the
use of false documents, in 2. A noncitizen national of the United States (See Instructions.)
connection with the completion of 3. A lawful permanent resident (Enter USCIS or A-Number.)
this form. I attest, under penalty
of perjury, that this information, 4. A noncitizen (other than Item Numbers 2. and 3. above) authorized to work until (exp. date, if any)
including my selection of the box
If you check Item Number 4., enter one of these:
attesting to my citizenship or
immigration status, is true and USCIS A-Number Form I-94 Admission Number Foreign Passport Number and Country of Issuance
OR OR
correct.
Signature of Employee Today's Date (mm/dd/yyyy)

If a preparer and/or translator assisted you in completing Section 1, that person MUST complete the Preparer and/or Translator Certification on Page 3.

Section 2. Employer Review and Verification: Employers or their authorized representative must complete and sign Section 2 within three
business days after the employee's first day of employment, and must physically examine, or examine consistent with an alternative procedure
authorized by the Secretary of DHS, documentation from List A OR a combination of documentation from List B and List C. Enter any additional
documentation in the Additional Information box; see Instructions.
List A OR List B AND List C
Document Title 1

Issuing Authority

Document Number (if any)

Expiration Date (if any)

Document Title 2 (if any) Additional Information

Issuing Authority

Document Number (if any)

Expiration Date (if any)

Document Title 3 (if any)

Issuing Authority

Document Number (if any)

Expiration Date (if any) Check here if you used an alternative procedure authorized by DHS to examine documents.
First Day of Employment
Certification: I attest, under penalty of perjury, that (1) I have examined the documentation presented by the above-named
(mm/dd/yyyy):
employee, (2) the above-listed documentation appears to be genuine and to relate to the employee named, and (3) to the
best of my knowledge, the employee is authorized to work in the United States.

Last Name, First Name and Title of Employer or Authorized Representative Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy)

Employer's Business or Organization Name Employer's Business or Organization Address, City or Town, State, ZIP Code

For reverification or rehire, complete Supplement B, Reverification and Rehire on Page 4.

Form I-9 Edition 08/01/23 Page 1 of 4
 LISTS OF ACCEPTABLE DOCUMENTS
All documents containing an expiration date must be unexpired.
* Documents extended by the issuing authority are considered unexpired.
Employees may present one selection from List A or a
combination of one selection from List B and one selection from List C.
Examples of many of these documents appear in the Handbook for Employers (M-274).

LIST A LIST B LIST C

Documents that Establish Both Identity Documents that Establish Employment
OR Documents that Establish Identity AND
and Employment Authorization Authorization

1. A Social Security Account Number card,

1. U.S. Passport or U.S. Passport Card 1. Driver's license or ID card issued by a State or unless the card includes one of the following
outlying possession of the United States restrictions:
2. Permanent Resident Card or Alien provided it contains a photograph or
Registration Receipt Card (Form I-551) information such as name, date of birth, (1) NOT VALID FOR EMPLOYMENT
gender, height, eye color, and address
3. Foreign passport that contains a (2) VALID FOR WORK ONLY WITH
temporary I-551 stamp or temporary 2. ID card issued by federal, state or local INS AUTHORIZATION
I-551 printed notation on a machine- government agencies or entities, provided it
readable immigrant visa (3) VALID FOR WORK ONLY WITH
contains a photograph or information such as DHS AUTHORIZATION
4. Employment Authorization Document name, date of birth, gender, height, eye color,
that contains a photograph (Form I-766) and address
2. Certification of report of birth issued by the
3. School ID card with a photograph Department of State (Forms DS-1350,
5. For an individual temporarily authorized FS-545, FS-240)
to work for a specific employer because
4. Voter's registration card 3. Original or certified copy of birth certificate
of his or her status or parole:
issued by a State, county, municipal
a. Foreign passport; and 5. U.S. Military card or draft record
authority, or territory of the United States
b. Form I-94 or Form I-94A that has 6. Military dependent's ID card bearing an official seal
the following: 4. Native American tribal document
7. U.S. Coast Guard Merchant Mariner Card
(1) The same name as the
5. U.S. Citizen ID Card (Form I-197)
passport; and 8. Native American tribal document
(2) An endorsement of the 6. Identification Card for Use of Resident
individual's status or parole as 9. Driver's license issued by a Canadian Citizen in the United States (Form I-179)
long as that period of government authority
endorsement has not yet 7. Employment authorization document
expired and the proposed For persons under age 18 who are issued by the Department of Homeland
employment is not in conflict unable to present a document Security
with any restrictions or listed above:
limitations identified on the form. For examples, see Section 7 and
10. School record or report card Section 13 of the M-274 on
6. Passport from the Federated States of uscis.gov/i-9-central.
Micronesia (FSM) or the Republic of the 11. Clinic, doctor, or hospital record
The Form I-766, Employment
Marshall Islands (RMI) with Form I-94 or Authorization Document, is a List A, Item
Form I-94A indicating nonimmigrant 12. Day-care or nursery school record
Number 4. document, not a List C
admission under the Compact of Free document.
Association Between the United States
and the FSM or RMI

Acceptable Receipts
May be presented in lieu of a document listed above for a temporary period.
For receipt validity dates, see the M-274.
● Receipt for a replacement of a lost, Receipt for a replacement of a lost, stolen, or Receipt for a replacement of a lost, stolen, or
stolen, or damaged List A document. OR damaged List B document. damaged List C document.
● Form I-94 issued to a lawful
permanent resident that contains an
I-551 stamp and a photograph of the
individual.
● Form I-94 with “RE” notation or
refugee stamp issued to a refugee.

*Refer to the Employment Authorization Extensions page on I-9 Central for more information.

Form I-9 Edition 08/01/23 Page 2 of 4

List A Document OR List B Document AND List C Document