American Piping Inspection, Inc. - Application for Employment



FOR OFFICE USE ONLY

Remove

Employment Application - Information

Remove
Yes
No
Yes
No
Yes
No
Yes
No

Education

Remove
Yes
No

Yes
No
Yes
No

References

Remove


Previous Employment (Previous 7 Years)

Remove
Yes
No
Yes
No
Yes
No

Military Service

Remove

Other

Remove

Disclaimer and Signature

Information to the applicant: As part of our procedure for processing your employment application, your personal and employment references may be verified. If you have misrepresented or omitted any facts on this application and our subsequently hired, you may be discharged from your job. You may make a written request for information derived from the verification of your references.


If necessary for employment, you may be required to supply your birth certificate or other proof of authorization to work in the United States, have a physical examination and/or drug test, or to sign a conflict of interest agreement and abide by the terms.
I certify that my answers are true and complete to the best of my knowledge.Information to the applicant: As part of our procedure for processing your employment application, your personal and employment references may be verified. If you have misrepresented or omitted any facts on this application and our subsequently hired, you may be discharged from your job. You may make a written request for information derived from the verification of your references.


If necessary for employment, you may be required to supply your birth certificate or other proof of authorization to work in the United States, have a physical examination and/or drug test, or to sign a conflict of interest agreement and abide by the terms

.
I certify that my answers are true and complete to the best of my knowledge.


Consent Form For Background Investigations

Physical Protection Program for Radioactive Materials 

12/16 Rev.0

I authorize and grant my consent to my employer, American piping Inspection (hereinafter or “the company”), to request the U.S. Nuclear Regulatory Commission (NRC), under Section 652 of the Energy Policy Act of 2005, to request criminal record information about me from the U.S. Attorney General, who will refer the request to the Federal Bureau of Investigation. I understand that the purpose of this information is solely to enable the company to determine my trustworthiness and reliability for unescorted assess to a Category 2 or greater quantity or of radioactive material as defined in the NRC’s Regulation in title 10 of the Code of Federal Regulations (10 CFR) Part 37, “physical Protection of Category 1 and Category 2 quantities of Radioactive Material.” I understand that American Piping Inspection, must obtain my sighed consent before any investigation or reinvestigation to determine my trustworthiness and reliability for such unescorted access.

I authorize and grant my consent to any authorized representative of American Piping Inspection, who is conducting my background investigation or reinvestigation, as defined in 10 CFR 37.25 “Background Investigations,” to obtain any information related to my activities from individuals, schools, residential, management agents, previous employers, criminal justice agencies, or other sources of information. This information may include, but is not limited to, my employment, and criminal history records.

I authorize the Federal Bureau of Investigation to disclose the records of my criminal history background investigation to my employer for the purpose of making a determination of my trustworthiness and reliability for unescorted access to a Category 2 or greater quantity of radioactive material. I understand that before making any determination to deny me this unescorted access, American Piping Inspection, will provide me a copy of the information on which it intends to base that determination. I further understand that before a final adverse determination, my employer must give me an opportunity to correct any inaccurate or incomplete information that is developed during the background investigation.

I understand that, for previous employers and other sources of information, separate specific release may be needed and that I may be contacted for such release at a later date. I authorize custodians of record and other sources of information pertaining to me to release at a later date. I authorize custodians of records and other Sources of information pertaining to me to release such information upon request of the investigator or other duly authorized representative of the company regardless of any previous agreement to the contrary.

I understand that the information released by records custodians and other sources of information is solely for the purpose of making a determination about my trustworthiness and reliability for unescorted access to the radioactive materials subject to 10 CFR Part 37 and that this information may be disclosed only as authorized by State or federal lay.

I understand that photocopies of this authorization and consent document with my signature are valid and that this authorization will remain in effect as long as I am authorized to obtain unescorted access to the radioactive materials subject to 10 CFR part 37.


Radiation History Request

Remove
Yes
No

Motor Vehicle Record Disclosure and Release

In connection with my ongoing employment or my application for employment, should I have or secure a position with American Piping Inspection, Inc. I understand that a motor vehicle record, which contains public record information, may be requested. I further understand that such report(s) will contain personal information and public record information containing my driving record from federal, state and other agencies that maintain such records, as well as independent services that provide driving record information.
I authorize, without reservation, any part or agency contacted to furnish the above mentioned information to American Piping Inspection, Inc. or its agent.


I hearby authorize procurement of my motor vehicle report. If hired, this authorization shall remain on file and shall serve as ongoing authorization for you to procure such reports at any time during my employment. American Piping Inspection, Inc.’s commercial auto insurer and agent will also use this information in conjunction with loss control and safety review efforts.