United States High School

Employment Application

AN EQUAL OPPORTUNITY EMPLOYER

EDUCATION

Position: STORE ASSOCIATE

Name: Kretzmer, Matthew Robert

Present Address: **** ****** ******, *******, ** - 32738 County: United States

Borough/Township:

Email: ad0gr6@r.postjobfree.com

SSN: XXX-XX-8410

Home Telephone: 386-***-****

Other Telephone Type: Select Other Telephone Type

Other Telephone: --

Education Name and

Location

Graduate

(Yes/No)

Diploma/

Degree/ GED/

Certification/

No. of

Credits

Course/

Major

Name At

Graduation

High School Pine Ridge

High School

Yes

College/Univ

ersity

Business/

Trade/

Technical

Nursing/

Medical

Graduate

Work or

Other (incl

.Military)

BACKGROUND

IF NO; WHY DID YOU LEAVE YOUR LAST JOB? Never had a job Skills

ARE YOU VACCINATED AGAINST COVID-

19?

Yes

WHAT SHIFT ARE YOU MOST

INTERESTED IN WORKING?

ANY

ARE YOU ABLE TO TRAVEL TO

ANOTHER STORE IF NEEDED? (NOT

REQUIRED)

No

ARE YOU AVAILABLE TO WORK

WEEKENDS?

Yes

IF HIRED, WHEN COULD YOU START? As soon as possible ARE YOU LEGALLY ELIGIBLE TO WORK

IN THE UNITED STATES?

Yes

ARE YOU CURRENTLY WORKING? No

DO YOU HAVE ANY FRIENDS/RELATIVES

THAT WORK HERE?

No

ARE YOU 18 YEARS OF AGE OR OLDER? Yes

I UNDERSTAND AND ACKNOWLEDGE

THAT AS A CONDITION OF

EMPLOYMENT, I WILL OR MAY BE

SUBJECT TO A BACKGROUND AND

DRUG SCREEN THAT WILL REQUIRE

CLEAR RESULTS.. FURTHERMORE, I

UNDERSTAND THAT THIS IS A DRUG

AND ALCOHOL-FREE WORKPLACE.

CHECK YES TO ACKNOWLEDGE.

Yes

Hard working

Communication

Teamworker

LICENSE INFORMATION

No License Information Entered

EMPLOYMENT INFORMATION

No Employment history entered

ATTACHMENTS

No Attachments

CERTIFICATION

Under pain of perjury, I, Matthew Robert Kretzmer, do certify that I have electronically signed this application and that the information is true and correct to the best of my knowledge, information and belief. I understand that if employed, falsified statements on this application shall be considered sufficient cause for dismissal. I agree to the these terms

Date: 10-05-23

ACKNOWLEDGMENT AND AUTHORIZATION FOR BACKGROUND CHECK I acknowledge receipt of the separate document entitled DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of "consumer reports" and/or "investigative consumer reports" by FMS - Ascend Grocery, LLC (Employer), and its designated agents and representatives at any time after receipt of this authorization and throughout my employment, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university

(public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by HR Screening Services, Inc., 521 Cedar Way, Oakmont, PA 15139, 800-***-****, www.hrscreening.com and/or Employer. I agree that a facsimile ("fax"), electronic or photographic copy of this Authorization shall be as valid as the original.

New York applicants only: Upon request, you will be informed whether or not a consumer report was requested by the Employer, and if such report was requested, informed of the name and address of the consumer reporting agency that furnished the report. You have the right to inspect and receive a copy of any investigative consumer report requested by the Employer by contacting the consumer reporting agency identified above directly. By signing below, you acknowledge receipt of Article 23-A of the New York Correction Law.

https://www.criminaljustice.ny.gov/pio/correction-law-article-23a.pdf New York City applicants only: You acknowledge and authorize the Employer to provide any notices required by federal, state or local law to you at the address(es) and/or email address(es) you provided to the Employer.

Washington State applicants only: You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

Minnesota and Oklahoma applicants only: Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Employer. California applicants or employees only: By signing below, you also acknowledge receipt of the Disclosure Regarding Background Investigation Pursuant to California Law. Please check this box if you would like to receive a copy of an investigative consumer report or consumer credit report if one is obtained by the Company at no charge whenever you have a right to receive such a copy under California law. [] New York and Maine applicants or employees only - You have the right to inspect and receive a copy of any investigative consumer report requested by contacting the consumer reporting agency identified above directly. You may also contact the Company to request the name, address and telephone number of the nearest unit of the consumer reporting agency designated to handle inquiries, which the Company shall provide within 5 days. Oregon applicants or employees only: Information describing your rights and under federal and Oregon law regarding consumer identity theft protection, the storage and disposal of your credit information and remedies available should you suspect or find that the Company has not maintained secured records is available to you on request. Los Angeles residents/applicants only: View the LA Notice to Applicants and Employees for Private Employers.

https://bca.lacity.org/Uploads/fciho/Ban%20the%20Box%20Poster%20-

%20Private%20Employers%2C%20as%20of%208.23.18.pdf

San Francisco residents/applicants only: View the San Francisco Fair Chance Ordinance.

https://sfgov.org/olse/sites/default/files/FCO%20poster2020_0.pdf Signature: Matthew Robert

Kretzmer

(ip: 104.28.195.166 date:

10/05/2023 03:47 PM)

Date: 10/5/2023

Printed Name: Matthew Robert

Kretzmer

DISCLOSURE REGARDING "INVESTIGATIVE CONSUMER REPORT" BACKGROUND INVESTIGATION

FMS - Ascend Grocery, LLC [Employer and its designated agents and representatives] (the

"Company"), to which you have applied for employment, may request an investigative consumer report about you from a third party consumer reporting agency, in connection with your employment or application for employment (including independent contractor or volunteer assignments, as applicable). An "investigative consumer report" is a background report that includes information from personal interviews (except in California, where that term includes background reports with or without information obtained from personal interviews). The most common form of an investigative consumer report in connection with your employment is a reference check through personal interviews with sources such as your former employers and associates, and other information sources. The investigative consumer report may contain information concerning your character, general reputation, personal characteristics, mode of living, or credit standing. You may request more information about the nature and scope of an investigative consumer report, if any, by contacting the Company. You have the right, upon written request made within a reasonable time, to request (1) whether an investigative consumer report has been obtained about you, (2) disclosure of the nature and scope of any investigative consumer report and (3) a copy of your report. These reports will be conducted by HR Screening Services, Inc., 521 Cedar Way, Oakmont, PA 15139, 800-***-****, www.hrscreening.com . This disclosure is not limited to your application for employment, but is intended to allow the Company to obtain, from any outside organization, types of investigative consumer reports throughout the course of your employment except to the extent prohibited by law. Signature: Matthew Robert

Kretzmer

(ip: 104.28.195.166 date:

10/05/2023 03:47 PM)

Date: 10/5/2023

Printed Name: Matthew Robert

Kretzmer

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