Central Refrigerated Service, Inc. Security Clearance Request Conviction Form Please Print Clearly Last name:                                         First:                                               Middle:                                    Other names (Maiden, Married, Etc.):                                                               SSN:                                   Address:                                                  City:                                              State:          Zip:                 Date of birth:                                           Daytime phone:                                      After hours phone:                                  Current Drivers License:                                           State of Issue       (You are allowed only one current license) List any licenses previously held:                                                                                                               Number of misdemeanor convictions:            Number of felony convictions:               Type of conviction 1: M / F Description of charge:                                                                                         Date of arrest:      /     /       Date of conviction:      /     /       Location County:                                             State/Country:                                   Sentence:                                         Time Served:                           Dates of probation - From:      /     /      - To:      /     /      Parole - From:      /     /      - To:      /     /       Type of conviction 2: M / F Description of charge:                                                                                         Date of arrest:      /     /       Date of conviction:      /     /       Location County:                                             State/Country:                                   Sentence:                                         Time Served:                           Dates of probation - From:      /     /      - To:      /     /      Parole - From:      /     /      - To:      /     /       Type of conviction 3: M / F Description of charge:                                                                                         Date of arrest:      /     /       Date of conviction:      /     /       Location County:                                             State/Country:                                   Sentence:                                         Time Served:                           Dates of probation - From:      /     /      - To:      /     /      Parole - From:      /     /      - To:      /     /       Any other arrests or convictions:                                                                                                                  Any charges pending now:                                                                                                                           Please describe what happened:                                                                                                                    Use the back side of this form if more room is needed for your description. Be sure to fax both sides if necessary. I authorize Central Refrigerated Service, Inc. to conduct any investigation including consumer investigative reports of my personal, driving and employment history. I authorize any former employer, person, firm, corporation, or government agency to give Central Refrigerated Service, Inc. any information they may have regarding me. I also release Central Refrigerated Service, Inc. and all providers of information from any liability as a result of receiving/furnishing this information. I understand that State, Federal laws or FCRA regulations entitle me to be notified that these investigations may be conducted, and may require Central refrigerated Service, Inc. to offer me a copy of these consumer investigative reports and a copy of my consumer rights under the FCRA. I hereby acknowledge this notification and release Central Refrigerated Service, Inc. from any further notification requirements and from any requirements to provide me a copy of any and all consumer investigative reports or a copy of my Consumer rights, unless I so request at a later date. I certify that the information contained herein is true and complete. I understand that falsification of information can lead to refusal of employment or termination. Applicants Signature:                                                                                Date:      /     /        Do not enter anything below this point (office use only). Forward this form to the security department with complete application Name of Recruiter:                                                                        Phone: 1-800-777-9100 ext              Security department approval:                                                                         Date:      /     /       Security personal signature: