Online Application

EMPLOYEE INFORMATION
Name*
First Last
Phone*
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Please provide any additional addresses used in the past 3 years:
*
DOB SSN Referred By
Emergency Contact's Name*
Emergency Contact's Phone*
Are you legally eligible to work in the United States?*
- Yes
- No
Are you 18 years of age or older?*
- Yes
- No
Are you 21 years of age or older?*
- Yes
- No
Have you previously worked for Gowan Construction/Gowan Farms/4G Farms?*
- Yes
- No
If Yes, when?*
Has your license, permit or privilege to operate a motor vehicle ever been revoked or suspended, denied a license or permit or been convicted of a DUI?*
- Yes
- No
If Yes, please list dates and details*
Have you ever tested positive or refused to take any drug or alcohol test?*
- Yes
- No
If Yes, please provide details*

DRIVERS LICENSE INFORMATION
List all valid Driver’s Licenses that you currently hold or have held in the last 3 years*
State License # Type/Class Expiration Date
GENERAL INFORMATION
Date you can start*
Salary/Wage expected*
Employment type sought*
- Labor
- Flagger
- Operator
- Truck Driver
- Other
Type of Work (be specific)*
Check if you are willing to accept*
- Full Time
- Part Time
- Year Round
- Temporary
- Seasonal
List special skills/abilities/certificates/license(s)/equipment operated
Are you physically capable of bearing weight of 50 lbs or more 3 feet off the ground for 60 seconds?*
- Yes
- No
Are you able to perform the essential functions of this job with or without reasonable accommodations?*
- Yes
- No
If accommodations are needed, please describe

TRUCK DRIVERS ONLY – OTHER APPLICANTS MAY CONTINUE TO NEXT PAGE
DRIVING EXPERIENCE
Class of Equipment Equipment Type Date Approx. Miles
List states operated in during the last three (3) years
Have you had any traffic convictions and/or forfeitures in the past three (3) years – other than parking violations?
If yes, please provide the following information.
Date Location Charge or Offense
Have you had any accidents in the last three (3) years?
If yes, please provide the following information.
Date Type/Nature of Accident Location Injuries or Fatalities
Have you ever been disqualified from driving a commercial motor vehicle for violations of Federal Motor Carrier Safety Regulations, State or Local Regulations?
- Yes
- No
If yes, please explain in detail

IMPORTANT NOTICES TO ALL EMPLOYEES, PLEASE READ BEFORE SIGNING

In connection with my application for employment (including contract for services) with Gowan Construction, Inc., I understand that consumer reports, which may contain public record information, may be requested from other agencies. These reports may include the following types of information: names and dates of previous employers, reason for termination or employment, work experience, accidents, etc. I further understand that such reports may contain public record information concerning my driving record, workers’ compensation claims, credit, bankruptcy proceedings, criminal record, etc., from federal, state and other agencies with maintain such records.
Disclosure and Release I authorize, without reservation, any party or agency contacted to furnish the above mentioned information.
I hereby authorize procurement of consumer report(s). If hired (or contracted) this authorization shall remain on file and shall serve as ongoing authorization for you to procure consumer reports at any time during my employment (or contract) period.
Drug and Alcohol Policy Receipt I understand Gowan Construction, Inc. has a Controlled Substance & Alcohol Testing Program and authorize the pre-employment Drug and Alcohol test. Until all testing information has been reviewed any offer of employment made is conditional. This means that an offer of employment can be withdrawn.
I understand the Federal Motor Carrier Safety Regulations as it pertains to me. Until all background information and driver qualification requirements have been verified by the Company Safety Department, any offer of employment made is conditional. This means that an offer of employment may be withdrawn. Areas that will be verified includes but are not limited to:

Past Employment Verification	Duration of Past Commercial Driving Experience
Type of Equipment Driven	Company Qualification Requirements
DOT Qualification Requirements	DOT Physical Qualification Requirements
Driver Record Check (MVR)	Drug and Alcohol Screening Results

You have the right to review information provided by previous employers and the right to correct that information, the right to have errors in the information corrected by the previous employer, and for that previous employer to re-send the corrected information to the prospective employer. You have the right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.
I understand that the information in this application will be used and that prior employers will be contracted for purposes of investigation as required by Section 391.23 of the Federal Motor Carrier Safety Regulations and other purposes. I also understand that I have due process rights regarding information received as part of this background check. This certifies that this application was completed by me. All information in this application is true and complete to the best of my knowledge. Any conditional offer of employment or actual employment does not constitute a guarantee of continued employment. I understand that misrepresentation or omission of information or facts may result in my rejection or dismissal.

*
- I understand and accept above mentioned notices
Date*
MM slash DD slash YYYY

COMBINED DISCLOSURE NOTICE AND AUTHORIZATION REGARDING BACKGROUND CONSUMER REPORTS (Important: Please read carefully before signing.)
The Fair Credit Reporting Act requires that we inform you that a background investigation may be conducted as part of our screening and hiring process. This may include an inquiry to obtain information regarding your character, employment history, general reputation, personal characteristics, police record, education, qualifications, motor vehicle record, mode of living and/or credit and indebtedness. The primary objective of any investigation will be to verify information you provided on your application or during the interview process in connection with your application for and/or continued employment (or contract) with the company. A consumer report and/or an investigative consumer report may be obtained at any time during the application process or during your employment with the company. Upon timely written request to our personnel department, and within 5 days of the request, the name, address and phone number of the reporting agency and the nature and scope of the report (if one is made) will be provided to you. You have the right to request details of the report from the consumer-reporting agency. Before any adverse action is taken, based in whole or in part on the information contained in the consumer report, you will be provided a copy of the report, the name, address and telephone number of the reporting agency, a summary of your rights under the Fair Credit Reporting Act, as well as additional information on your rights under the law. The items of information requested below are required to process your background investigation. They are intended solely for that purpose and will not be used in a discriminatory manner for the making of business decisions. (A Copy of ‘A Summary of Your Rights Under the Fair Credit Reporting Act’ is included with this authorization)
Full Name of Applicant*
Other Names Used & Date Changed

Including Maiden Name/Year changed
Telephone Number/s*
Current Address*
Street Address City State ZIP Code
Previous Address
Street Address City State ZIP Code
*
Social Security #
Date of Birth*
MM slash DD slash YYYY
Driver's License #*
State*
Professional License/s
State
Type
Number
Have you ever been charged with or convicted of a Misdemeanor or Felony crime?*
- Yes
- No
If yes, please explain in some detail, including what county and state, and in what year
I hereby authorize Gowan Construction and/or Global Safety Network and their agents, without any reservation, to investigate my background as it pertains to employment history and performance, personal and professional references, educational history, licenses and information contained in public records, including, but not limited to, credit, criminal, motor vehicle data and workers compensation. I hereby release all persons, companies or other entities furnishing such information from liability and responsibility in connection herewith. I further authorize ongoing procurement of the types of reports mentioned herein at any time during my employment (or contract) with the company. A photocopy of this document may be substituted for the original.
- I verify this information is correct.
Date*
MM slash DD slash YYYY
MN/CA/OK Residents Only: Do you wish to receive a copy of your consumer report?
- Yes
- No

Para informacion en espanol, visite www.consumerfinance.gov/learnmore o escribe a la Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, D.C. 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 www.consumerfinance.gov/learnmore or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, D.C. 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 the 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 will be entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See 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 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 consumer 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 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 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 information about your federal rights, contact:
TYPE OF BUSINESS: CONTACT: 1.a. Banks, savings associations, and credit unions with total assets of over $10 million and their affiliates: b. Such affiliates that are not banks, saving associations, or credit unions also should list, in addition to the Bureau: a. Bureau of Consumer Financial Protection 1700 G Street N. W., Washington, DC 20552 b. Federal Trade Commission: Consumer Response Center - FCRA Washington, DC 20580 1-877-382-4357 2. To the extent not include 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 25 A of the Federal Reserve Act: c. Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured state savings associations: d. Federal Credit Unions: 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 3. Air carriers: Asst. General Counsel for Aviation Enforcement & Proceedings, Aviation Consumer Protection Division Department of Transportation 1200 New Jersey Avenue, S.E., Washington, DC 20590 4. Creditors Subject to Surface Transportation Board: Office of Proceedings, Surface Transportation Board Department of Transportation 395 E. Street, S.W., Washington, DC 20423 5. Creditors Subject to Packers and Stockyards Act: Nearest Packers and Stockyards Administration area supervisor 6. Small Business Investment Companies: Associate Deputy Administrator for Capitol Access United States Small Business Administration 409 Third Street, SW, 8th Floor, Washington, DC 20416 7. Brokers and Dealers: Securities and Exchange Commission 100 F Street NE, Washington, DC 20549 8. Federal Land Banks, Federal Land Bank Associations, Federal Intermediate Credit Banks, and Production Credit Associations: Farm Credit Administration 1501 Farm Credit Drive McLean, VA 22102-5090 9. Retailers, Finance Companies, and All other Creditors Not Listed Above: FTC Regional Office for region in which the creditor operates or Federal Trade Commission: Consumer Response Center – FCRA, Washington, DC 20580 (877) 382-4357

AUTHORIZATION FOR FILE REVIEW OR RELEASE OF COPIES OF WORKERS’ COMPENSATION CLAIM FILE
*
- I hereby authorize Gowan Construction and/or Global Safety Network to review and/or receive copies of any or all parts of the Minnesota workers’ compensation claim file(s) maintained by the Department of Labor and Industry (DLI) for the employee and date(s) of injury indicated below.
EMPLOYEE*
WID or SSN*
DATE(S) OF INJURY
EMPLOYER
INSURER (if known)
• Following receipt of this properly completed authorization, DLI may release information from the workers’ compensation claim file about the above-named employee, employer and insurer, including the employee’s worker identification number (WID) and social security number, that would not otherwise be accessible to the public. The WID is a unique number assigned by DLI to an injured worker and may be used instead of the employee’s SSN.
• Once this information is released, DLI does not control how it is used or further distributed by the recipient.
• A copy of this authorization may be used in the same manner and with the same effect as the original document.
• This authorization is valid for six months from the date signed, or until this consent is withdrawn by notifying DLI in writing at the above address or facsimile number.
Print name of person authorizing release*
Signature of person authorizing release (please type name to authorize)*
Date signed*
MM slash DD slash YYYY
I am authorized to sign this form because I am the*
- employee
- parent/guardian of a minor or incapacitated employee (if not the parent, attach a court order documenting guardianship)
- employer (state title at employer)
- insurer (state title at insurer)
- dependent of deceased employee (state relationship)
- representative of employee’s estate (attach court order)
- representative of the DLI Special Compensation Fund
NOTICE: Information concerning disability may not be used to make a job decision unless state or federal law permits use of this information. Unless authorized by state or federal law, any use or distribution of this information beyond that authorized by the subject of this data is prohibited. Questions concerning use of disability information may be directed to the Minnesota Department of Human Rights at (651) 296-5663 or 1-800-657-3704.

INSTRUCTIONS FOR AUTHORIZATION TO REVIEW OR RELEASE COPIES OF MINNESOTA WORKERS’ COMPENSATION CLAIM FILE

Minnesota Statutes, § 176.231, subdivision 9 requires that information in a workers’ compensation claim file maintained by the Department of Labor and Industry (department) may not be released without the authorization of the employee, employer, insurer, or dependent of the deceased employee. Minnesota Rules, part 5220.2880, subpart 1, requires an authorization to:
• be in writing;
• be signed and dated within the last six months by the employee or legal guardian, employer, insurer, special compensation fund, or dependent of a deceased employee for the specified date of injury; and
• specify who is authorized to review the file.
The department may ask for additional information to verify the identity of the person authorizing the release or the relationship of the person to a party to the claim. Claim file information may not be released over the telephone without this authorization in the department’s file. The department will only copy or permit review of claim file information for the dates of injury indicated on the authorization. If the authorization is for all dates of injury for an employee, indicate “any and all” dates of injury. An employer or insurer must obtain an authorization from the employee to review a workers’ compensation file for which it is not a party.
This authorization must be signed and dated by an authorized person and filed with the Department of Labor and Industry by mail or in person.

In Person:	Mailing Address:
Department of Labor and Industry	Department of Labor and Industry
Workers’ Compensation File Review	Workers’ Compensation File Review
443 Lafayette Road N.	PO Box 64226
St. Paul, MN 55155-4301	St. Paul, MN 55164-0226

If you have questions, the worker’s compensation file review office can be reached at 651-284-5200; toll-free: 800-342-5354; and TTY: 651-297-4198.

EMPLOYEE INFORMATION

DRIVERS LICENSE INFORMATION

GENERAL INFORMATION

MILITARY INFORMATION

EDUCATION/TRAINING

TRUCK DRIVERS ONLY – OTHER APPLICANTS MAY CONTINUE TO NEXT PAGE

DRIVING EXPERIENCE

EMPLOYMENT HISTORY

IMPORTANT NOTICES TO ALL EMPLOYEES, PLEASE READ BEFORE SIGNING

VOLUNTARY EEO/AA SELF-IDENTIFICATION FORM

COMBINED DISCLOSURE NOTICE AND AUTHORIZATION REGARDING BACKGROUND CONSUMER REPORTS (Important: Please read carefully before signing.)

Para informacion en espanol, visite www.consumerfinance.gov/learnmore o escribe a la Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, D.C. 20552.

AUTHORIZATION FOR FILE REVIEW OR RELEASE OF COPIES OF WORKERS’ COMPENSATION CLAIM FILE

INSTRUCTIONS FOR AUTHORIZATION TO REVIEW OR RELEASE COPIES OF MINNESOTA WORKERS’ COMPENSATION CLAIM FILE

GOWAN Construction, Inc. is an Equal Opportunity Employer

Phone

State	License #	Type/Class	Expiration Date

Class of Equipment	Equipment Type	Date	Approx. Miles

Date	Location	Charge or Offense

Date	Type/Nature of Accident	Location	Injuries or Fatalities