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Supplement to FORM 612
EMPLOYEE NAME:____________________________________________________________ Social Security Number:___________________________________________________________
1. Are you willing to work nights?-------------------------------------------------YES___, NO___. 2. Are you willing to work weekends?---------------------------------------------YES___, NO___. Note: It is important that you give complete and truthful answers to questions 3 through 6. If you answer "YES" to any of them, provide your explanation(s) in item 7. Include convictions resulting from a plea of nolo contendere (no contest). Omit: 1) traffic fines of $100.00 or less; 2) any violation of law committed before your 16th birthday; 3) any violation of law committed before your 18th birthday, if finally decided in juvenile court or under a Youth Offender law; 4) any conviction set aside under the Federal Youth Corrections Act or similar State Law; 5) any conviction whose record was expunged under Federal or State law. We will consider the date, facts and circumstances of each event you list. In most cases you can still be considered for Federal / NAFI jobs. However, if you fail to tell the truth or fail to list all relevant events, or circumstances, this may be grounds for not hiring you, for firing you after you begin work, or for criminal prosecution (18 USC 1001). 3. Have you ever been convicted of, or forfeited collateral for any felony violation? ----YES ___, NO___. (Generally, a felony is defined as any violation of law punishable by imprisonment of longer than 1 year, except for violations called misdemeanors under State law which are punishable by imprisonment of two years or less). 4.Have you ever been convicted of, or forfeited collateral of any firearms or explosive violations? ----YES___, NO___. 5. Are you now under charges for any violation of the law?-----------------------------YES ___, NO ___. 6. During the last 10 years have you forfeited collateral, been convicted, been imprisoned, been on probation, or been on parole? Do not include violations reported in 3, 4, or 5, above.-------------------------YES ___, NO ___. 7. If "YES" in 3 through 6, explain each violation. Give place of occurrence and name / address of police or court involved. (If more space is needed, please use back of form). _____________________________________________________________________________________ _____________________________________________________________________________________ 8. Reason for leaving last position. ( Use other side if necessary)____________________________________ _____________________________________________________________________________________ IMPORTANT NOTE: A BACKGROUND INVESTIGATION WILL BE CONDUCTED Applicant Signature: ________________________________________ Date: ________________________
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