Employment Form

I authorize Cheney Door Company, Inc to make investigations (including contracting current and prior employers) into my
personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment
decision. I hereby release employers, schools, health care providers, and other persons from all liability in responding to inquiries
and releasing information in connection with my application.
In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in
discharge. I also understand that I am required to abide by all rules and regulations of the Company.
I understand that the information I provide regarding my current and/or prior employers may be used, and those employer(s) will
be contacted for the purpose of investigating my safety performance history as required by 49 CFR 391.23. I understand that I have
the right to:
• Review information provided by current/previous employers;
• Have errors in the information corrected by previous employers, and for those previous
employers to resend the corrected information to the prospective employer; and
• Have a rebuttal statement attached to the alleged erroneous information, if the previous
employer( s) and I cannot agree on the accuracy of the information.
This certifies that I completed the attached application, and that all entries on it and information in
it are true and complete to the best of my knowledge.