Prime – Electrical Application Form

EQUAL OPPORTUNITY EMPLOYER. It is our policy to abide by all Federal and State laws prohibiting employment discrimination solely on the basis of a person’s race, color, creed, national origin, religion, age (over), sex, marital status, or physical or mental disability, except where a reasonable, bona fide occupational qualification exists.
Date*
Date Format: MM slash DD slash YYYY
Name*
First Name Last Name
Email*
SOCIAL SECURITY #*
Address City State ZIP Code
HOME PHONE #*
EMERGENCY PHONE #*
CELL PHONE #*
POSITION FOR WHICH YOU ARE APPLYING?
Job Type
- TEMPORARY
- FULL TIME
- PART TIME
Days and times available

Education SCHOOL NAME/ADDRESS DEGREE/MAJOR COURSE OF STUDY
ELECTRICAL LICENSE?
- Yes
- No
TYPE, LICENSE # AND EXP. DATE
DO YOU HAVE TRANSPORTATION TO AND FROM THE JOBSITE, IN OR OUT OF TOWN?
- Yes
- No
LIST ANY OTHER EDUCATION, TRAINING, SPECIAL SKILLS OR CERTIFICATES/LICENSES THAT YOU POSSESS RELATED TO THIS JOB.
LIST ANY MACHINES OR EQUIPMENT ON WHICH YOU ARE QUALIFIED AND EXPERIENCED IN OPERATING.
LIST ANY LANGUAGES THAT YOU FLUENTLY:
Language Speak Read Write
LIST ANY OFFICE SKILLS THAT YOU HAVE, INCLUDING ANY SOFTWARE THAT YOU HAVE WORKED WITH.
DO YOU HAVE A CURRENT PASSPORT?
- Yes
- No
WHAT IS THE EXPIRATION DATE?
Date Format: MM slash DD slash YYYY
DO YOU HAVE A CURRENT TWIC Card?
- Yes
- No
WHAT IS THE EXPIRATION DATE?
Date Format: MM slash DD slash YYYY
ARE YOU 16 YEARS OF AGE OR OLDER?
- Yes
- No
Age
WERE YOU PREVIOUSLY EMPLOYED BY PRIME ELECTRICAL?
- Yes
- No
When?
Please add LIST ANY RELATIVES WORKING FOR PRIME ELECTRICAL.
HAVE YOU EVER BEEN CONVICTED OF ANY CRIMINAL OFFENSE (MISDEMEANOR OR FELONY)
- Yes
- No
LIST YEAR, CHARGE AND OUTCOME OF EACH OFFENSE
HAVE YOU EVER PLED GUILTY OR NOLO CONTENDRE (NO CONTEST) TO A CRIMINAL CHARGE IN ORDER TO QUALIFY FOR DEFFERED AJUDICATION?
- Yes
- No
EXPLAIN
HAVE YOU EVER BEEN ON ANY TYPE OF PROBATION AS A RESULT OF A CRIMINAL CHARGE?
- Yes
- No
LIST
IF YOU ARE CURRENTLY CHARGED WITH A CRIMINAL OFFENSE AND AWAITING TRIAL PLEASE EXPLAIN:
HAVE YOU EVER BEEN CHARGED WITH DWI OR DUI?
- Yes
- No
LIST

LIST ALL WORK EXPERIENCE BEGINNING WITH THE PRESENT OR MOST RECENT JOB.
From
Date Format: MM slash DD slash YYYY
To
Date Format: MM slash DD slash YYYY
NAME OF EMPLOYER
TYPE OF BUSINESS
ADDRESS
CITY/STATE/ZIP
TELEPHONE #
NAME OF SUPERVISOR
MAY WE CONTACT?
- Yes
- No
EMPLOYED
- Yes
- No
YOUR TITLE
DUTIES
REASON FOR LEAVING
LAST SALARY
From
Date Format: MM slash DD slash YYYY
To
Date Format: MM slash DD slash YYYY
NAME OF EMPLOYER
TYPE OF BUSINESS
ADDRESS
CITY/STATE/ZIP
TELEPHONE #
NAME OF SUPERVISOR
MAY WE CONTACT?
- Yes
- No
EMPLOYED
- Yes
- No
YOUR TITLE
DUTIES
REASON FOR LEAVING
LAST SALARY
From
Date Format: MM slash DD slash YYYY
To
Date Format: MM slash DD slash YYYY
NAME OF EMPLOYER
TYPE OF BUSINESS
ADDRESS
CITY/STATE/ZIP
TELEPHONE #
NAME OF SUPERVISOR
MAY WE CONTACT?
- Yes
- No
EMPLOYED
- Yes
- No
YOUR TITLE
DUTIES
REASON FOR LEAVING
LAST SALARY
From
Date Format: MM slash DD slash YYYY
To
Date Format: MM slash DD slash YYYY
NAME OF EMPLOYER
TYPE OF BUSINESS
ADDRESS
CITY/STATE/ZIP
TELEPHONE #
NAME OF SUPERVISOR
MAY WE CONTACT?
- Yes
- No
EMPLOYED
- Yes
- No
YOUR TITLE
DUTIES
REASON FOR LEAVING
LAST SALARY
LIST THREE PEOPLE WHO ARE NOT EMPLOYERS OR RELATIVES THAT HAVE KNOWN YOU FOR AT LEAST THREE YEARS.
NAME AND ADDRESS OCCUPATION PHONE #
PLEASE INCLUDE ANY OTHER INFORMATION YOU THINK WOULD BE HELPFUL TO US IN CONSIDERING YOU FOR EMPLOYMENT, SUCH AS ADDITIONAL WORK EXPERIENCE, ARTICLES/ BOOKS PUBLISHED, ACTIVITIES, HONORS RECEIVED, ETC. (YOU MAY OMIT ALL INFORMATION THAT WOULD INDICATE AGE, SEX, RACE, RELIGION, COLOR, NATIONAL ORIGIN, OR HANDICAP).

AGREEMENT*
PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY.
I HEREBY AFFIRM THAT THE INFORMATION PROVIDED ON THIS APPLICATION – AND ACCOMPANYING
RESUME, IF ANY – IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I ALSO AGREE THAT
FALSIFIED INFORMATION OR SIGNIFICANT OMISSIONS MAY DISQUALIFY ME FROM FURTHER
CONSIDERATION FOR EMPLOYMENT AND MAY BE CONSIDERED JUSTICIATION FOR DISMISSAL IF
DISCOVERED AT A LATER DATE.
I AUTHORIZE ALL PERSONS LISTED ABOVE – AND ON THE ACCOMPANYING RESUME, IF ANY – TO PRIME
ELECTRICAL GIVE ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT, EDUCATION,
AND ANY OTHER PERTINENT INFORMATION THEY MAY HAVE – PERSONAL OR OTHERWISE. I RELEASE
ALL PARTIES, SUCH PERSONS, AND PRIME ELECTRICAL FROM LIABILITY FOR ANY DAMAGE THAT MAY
RESULT FROM FURNISHING SAME TO PRIME ELECTRICAL.
I UNDERSTAND THAT PRIME ELECTRICAL WILL PROVIDE WORKERS’ COMPENSATION INSURANCE FOR
ITS EMPLOYEES. IN THE EVENT OF ANY INJURY IN THE WORKPLACE, I AGREE THAT MY SOLE REMEDY
LIES IN COVERAGE UNDER PRIME ELECTRICAL WORKERS’ COMPENSATION INSURANCE POLICY.
I UNDERSTAND AND AGREE THAT I MAY BE REQUIRED TO TAKE A DRUG AND ALCOHOL SCREENING
TEST. I HEREBY GIVE MY VOLUNTARY CONSENT FOR A BLOOD AND/OR URINE SAMPLE TO BE
COLLECTED FROM ME AND SUBMITTED FOR TESTING. I ALSO CONSENT TO THE RELEASE OF THE TEST
RESULTS TO PRIME ELECTRICAL FOR ITS USE. I UNDERSTAND ANY POSITIVE DRUG OR ALCOHOL
RESULT MAY PRECLUDE MY EMPLOYMENT.
Signature*
Date*
Date Format: MM slash DD slash YYYY

PRIME ELECTRICAL SERVICES LLC APPLICANT PLEASE COMPLETE WILL OBTAIN A CONSUMER REPORT*
EXPLANATION & DISCLOSURE OF INTENT
PRIME ELECTRICAL SERVICES LLC utilizes a Consumer Reporting Agency (CRA) to conduct public records searches for
information such as criminal history. Such information is considered a Consumer Report under the Fair Credit Reporting Act. The
Cole Group, the CRA, will assist you in procurement of this job opportunity by providing to PRIME ELECTRICAL SERVICES
LLC verification of your background.

To accomplish this, you need to authorize and request that The Cole Group release all information in its files and to contact any
or all of the following information sources: courts, law enforcement agencies, correctional facilities, jails, Motor Vehicle Records
(permitted by 18 US Code 2721 (b)(6)(9)(13)(14)), and all other government public record repositories.
AUTHORIZATION, CONSENT & REQUEST*
By signing below, you are consenting to the following
I CONSENT to and REQUEST that The Cole Group create a Consumer Report and make inquiries necessary to verify the
information I have provided on my resume, application, and during interviews by and for PRIME ELECTRICAL SERVICES LLC.
I understand and agree that The Cole Group and PRIME ELECTRICAL SERVICES LLC have a PERMISSIBLE PURPOSE and
may now, or at any time in the future if I obtain this job, make inquiries concerning my criminal history and other public records
information maintained by law enforcement and government records repositories. I further request that the results of these
inquiries be communicated to and understand that the information will be utilized to evaluate me for possible current or future
employment, promotion or reassignment. I understand such information will not be utilized to violate state or federal equal
opportunity law.
Signature*
Date*
Date Format: MM slash DD slash YYYY

NOTICE & RIGHTS*
I Agree
NOTICE: You may write to The Cole Group at 5151 Katy Freeway, Suite 204 Houston, TX 77007 and request the nature and
substance of any information obtained from these sources. Please include a stamped and self-addressed envelope to insure
proper and accurate return of information.

By signing below you ACKNOWLEDGE your understanding of these disclosures, that you may contact The Cole Group, and that
you have been provided a copy of your rights under the Fair Credit Reporting Act:
Signature*
Date*
Date Format: MM slash DD slash YYYY

Para información en español, visite http://www.consumerfinance.gov/learnmore/ escribe a la Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.
The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to http://www.consumerfinance.gov/learnmore/ or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552. • You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment - or to take another adverse action against you - must tell you, and must give you the name, address, and phone number of the agency that provided the information. • You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your “file disclosure”). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if: • a person has taken adverse action against you because of information in your credit report; • you are a victim of identity theft and place a fraud alert in your file; • your file contains inaccurate information as a result of fraud; • you are on public assistance; • you are unemployed but expect to apply for employment within 60 days. In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See http://www.consumerfinance.gov/learnmore/ for additional information. • You have the right to ask for a credit score. Credit scores are numerical summaries of your credit- worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender. • You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See http://www.consumerfinance.gov/learnmore/ for an explanation of dispute procedures. • Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate. • Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old. • Access to your file is limited. A credit reporting agency may provide information about you only to people with a valid need - usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access. • You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to http://www.consumerfinance.gov/learnmore/. • You may limit “prescreened” offers of credit and insurance you get based on information in your credit report. Unsolicited “prescreened” offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at 1-888-5- OPTOUT (1-888-567-8688). • You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court. • Identity Theft victims and active duty military personnel have additional rights. For more information, visit http://www.consumerfinance.gov/learnmore/ .

States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. For more information about your federal rights, contact: TYPE OF BUSINESS: CONTACT: 1.a. Banks, savings associations, and credit unions with total assets of over $10 billion and their affiliates. b. Such affiliations that are not banks, savings associations, or credit unions also should list, in addition to the CFPB: 2. To the extent not included in item 1 above: a. National banks, federal savings associations, and federal branches and federal agencies of foreign banks. b. State member banks, branches and agencies of foreign banks (other than federal branches, federal agencies, and Insured State Branches of Foreign Banks), commercial lending companies owned or controlled by foreign banks, and organizations operating under section 25 or 25A of the Federal Reserve Act. c. Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured state savings associations. d. Federal Credit Unions 3. Air carriers 4. Creditors Subject to Surface Transportation Board 5. Creditors Subject to Packers and Stockyards Act, 1921 6. Small Business Investment Companies 7. Brokers and Dealers 8. Federal Land Banks, Federal Lank Bank Associations, Federal Intermediate Credit Banks, and Production Credit Associations 9. Retailers, Finance Companies, and All Other Creditors Not Listed Above a. Consumer Financial Protection Bureau 1700 G Street, N.W. Washington, DC 20552 b. Federal Trade Commission: Consumer Response Center - FCRA Washington, DC 20580 (877) 382-4357 a. Office of the Comptroller of the Currency Customer Assistance Group 1301 McKinney Street, Suite 3450 Houston, TX 77010-9050 b. Federal Reserve Consumer Help Center P.O. Box 1200 Minneapolis, MN 55480 c. FDIC Consumer Response Center 1100 Walnut Street, Box #11 Kansas City, MO 64106 d. National Credit Union Administration Office of Consumer Protection (OCP) Division of Consumer Compliance and Outreach (DCCO) 1775 Duke Street Alexandria, VA 22314 Asst. General Counsel for Aviation Enforcement & Proceedings Aviation Consumer Protection Division Department of Transportation 1200 New Jersey Avenue, S.E. Washington, DC 20590 Office of Proceedings, Surface Transportation Board Department of Transportation 395 E Street, S.W. Washington, DC 20423 Nearest Packers and Stockyards Administration area supervisor Associate Deputy Administrator for Capital Access United States Small Business Administration 409 Third Street, SW, 8th Floor Washington, DC 20416 Securities and Exchange Commission 100 F Street, N.E. Washington, DC 20549 Farm Credit Administration 1501 Farm Credit Drive McLean, VA 22102-5090 FTC Regional Office for region in which the creditor operates or Federal Trade Commission: Consumer Response Center-FCRA Washington, DC 20580 (877) 382-4357

The Cole Group will assist you in procurement of this job opportunity by providing to PRIME ELECTRICAL SERVICES LLC verification of your background, job skills, work history, experience, and dependability.
CONSENTS & REQUESTS*
I consent to and request that The Cole Group make inquiries necessary to verify the information I have provided on my resume, application, and during interviews by and for PRIME ELECTRICAL SERVICES LLC.
I understand and agree that The Cole
Group may now, or at any time in the future if I obtain this job, make inquiries concerning my past employment history (to include
pay, attendance, dates of employment, and reasons for leaving); education; financial responsibility; driving records including
Motor Vehicle Records (permitted by 18 US Code 2721 (b)(6)(9)(13)(14)), and criminal history. I further request that the results of
these inquiries be communicated to PRIME ELECTRICAL SERVICES LLC and understand that the information will be utilized to
evaluate me for possible current or future employment, promotion or reassignment. I understand that The Cole Group does not
inquire into or disseminate information related to a job applicant's physical and mental medical condition and medical history,
impairments, diagnoses, family medical history, injuries, workers' compensation claims, civil rights, and personal injury lawsuits.
Signature*
Date*
Date Format: MM slash DD slash YYYY

RELEASE OF LIABILITY*
I understand that the sole purpose of The Cole Group is to assist me in demonstrating my suitability for and procuring employment at PRIME ELECTRICAL SERVICES LLC.
To accomplish this, I authorize and request that The Cole Group release
all information in its files and contact any or all of the following information sources: former employers, courts, law enforcement
agencies, correctional facilities, jails, and all other government record repositories. I agree that any inaccurate information
provided about me shall not be the fault of The Cole Group or PRIME ELECTRICAL SERVICES LLC, and that sole responsibility
shall be attributed to the source of that information. Accordingly, I hereby release from liability and hold harmless The Cole
Group, PRIME ELECTRICAL SERVICES LLC, any contributing firm, individual, government agency or repository, and all of their
officers, employees, and agents, from any and all claims, actions or liability whatsoever which is in any way related to this or
subsequent inquiries of my personal history. NOTICE: You may write to The Cole Group at 5151 Katy Freeway, Suite 204
Houston, TX 77007 and request the nature and substance of any information obtained from these sources. Please include a
stamped and self-addressed envelope. You have been provided a summary of your rights under the Fair Credit Reporting Act.
Signature*
Date*
Date Format: MM slash DD slash YYYY
AUTHORIZATION FOR EMPLOYERS TO PROVIDE INFORMATION*
I hereby request the full disclosure of all information concerning my employment at your company, to include DATES OF EMPLOYMENT, my job title/position, pay, and REASON FOR LEAVING.
I release and hold harmless all former employers from
any damages, claims, causes of action and liability in reference to furnishing and verifying such information.
Signature*
Date*
Date Format: MM slash DD slash YYYY

From time to time, a dispute or disagreement may arise out of your application for employment, including the use of a check or investigation of your background (known as a Consumer Report). PRIME ELECTRICAL SERVICES LLC (“Company”) has retained The Cole Group to conduct the investigation and has provided and agreed to provide you all disclosures required by the federal Fair Credit Reporting Act and applicable state law. In any instance of a dispute related to any aspect of The Cole Group's check or investigation of your background, education, employment history, credit history, criminal history, references, and other matters that may be disclosed or discovered (“background check”), you and The Cole Group agree that if the dispute is not resolved as per the Fair Credit Reporting Act, any and all such disputes or disagreement shall be resolved exclusively through arbitration. This includes, but is not limited to, any disputes, disagreements, or causes of action arising out of or related to the federal Fair Credit Reporting Act, Title VII of the Civil Rights Act of 1964, the Americans with Disabilities Act, the Age Discrimination in Employment Act, any state or local civil rights or credit reporting law, and all other federal or state legislation or administrative regulations currently in effect or subsequently enacted which affects check or investigation of your background in conjunction with any application or candidacy for employment. This arbitration will be conducted in accordance with the Employment Arbitration Rules of the American Arbitration Association (“AAA”), a copy of which Rules can be found on the website address here: https:// www.adr.org/aaa/ShowProperty?nodeId=/UCM/ADRSTG_004362 or can be provided to you by request from The Cole Group. The arbitrator, who will be selected by mutual agreement of you and The Cole Group, shall permit adequate discovery and is empowered to award all remedies otherwise available in a court of competent jurisdiction. At the hearing, you and The Cole Group will have the right to present witnesses who will provide testimony under oath and to show admissible documents or other evidence supporting your and its position in the dispute. The arbitrator will decide all aspects of the dispute, both procedure and substance, based on the law. Any judgment rendered by the arbitrator may be entered and enforced by any court of competent jurisdiction. The arbitrator shall issue an award in writing and state the essential findings and conclusions on which the award is based. The decision of the arbitration will be final and binding, and may only be appealed in accordance with and subject to the limited standards set forth in the Federal Arbitration Act. The Cole Group shall pay all AAA fees and arbitrator costs and you will be responsible only for those costs that you would otherwise incur or elect to incur in a court of law. To the fullest extent permitted by applicable law, by signing this Arbitration Agreement, you and The Cole Group both waive the right to have any disputes or claims tried in court before a judge or jury. The mutual promise by The Cole Group, and you to arbitrate any and all disputes between them concerning the background check, rather than litigate them before the courts or other bodies, provides the consideration for this agreement to arbitrate. You agree to waive the right to file or participate in a class action as a class representative or as a putative class member, but that you will make any claim you bring in arbitration on an individual basis and the arbitrator will hear and decide the dispute on that basis. You agree that you and The Cole Group will make every effort to have your dispute decided within six (6) months of the date that you and The Cole Group select an arbitrator. You further agree that you and The Cole Group will each have one day to present your dispute at a hearing conducted by the arbitrator, but that either you or The Cole Group can ask the arbitrator to extend the amount of time for your/its presentation and that the request shall not be denied.

Accordingly, by signing this agreement, you and The Cole Group agree that each may bring claims against the other only in its/your individual capacity, and not as a plaintiff or class member in any purported class or representative proceeding.
I agree to comply and abide by the terms of this Arbitration Agreement.
Further, unless both you and the The Cole Group agree
otherwise, the arbitrator may not consolidate more than one person's claims, and may not otherwise preside over
any form of a representative or class proceeding.

Nothing in this Arbitration Agreement shall preclude either you or The Cole Group from seeking injunctive
relief in a court of law to protect, for instance, your right to engage in future employment or The Cole Group's
right to protect proprietary, confidential or trade secret information.

If a court of competent jurisdiction or arbitrator determines that the scope and/or operation of this agreement
is too broad to be enforced as written, The Cole Group and you intend that the court or arbitrator should reform
such provision to such narrower scope and/or operation as it determines to be enforceable. If, however, any term
or provision in this agreement is held to be illegal, invalid, or unenforceable under present or future law, and not
subject to reformation, then, unless as otherwise stated herein, (i) such provision shall be fully severable, (ii) this
agreement and the agreements contained within it shall be construed and enforced as if such provision was never
a part of this offer agreement, and (iii) the remaining provisions of this agreement shall remain in full force and
effect and shall not be affected by the illegal, invalid, or unenforceable provision or by its severance.

You understand that no supervisor, manager, co-worker, or representative of The Cole Group, other than the
President, Vice President or CFO has any authority to enter into any agreement contrary to the foregoing, and
that any such agreement must be in writing.
Applicant Signature*
Date*
Date Format: MM slash DD slash YYYY
On Behalf of The Cole Group
Printed name

Application new form

Prime Electrical

Step 1 of 12

Education	SCHOOL NAME/ADDRESS	DEGREE/MAJOR COURSE OF STUDY

Language	Speak	Read	Write

NAME AND ADDRESS	OCCUPATION	PHONE #