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Position(s) Applied For
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First Name
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May We Contact You at Work?
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I certify that I am a U.S. citizen, permanent resident or a Foreign National with authorization to work in the United States.
Yes
No
Have you served in the U.S. Armed Services?
Yes
No
If Yes, Branch:
Are you an enrolled member of a federally recognized tribe?
Yes
No
If Yes, Tribe:
Enrollment Number:
Are you related to any current TDN / L7C Employee?
Yes
No
Date you would be able to start active employment:
Have you ever been discharged or forced to resign from any employment?
Yes
No
If Yes, Explain:
Have you ever been convicted of a felony?
Yes
No
If Yes, Explain:
Do you have any condition which might limit your ability to perform the job(s)?
Yes
No
If yes, how can we accommodate your needs?
High School
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May we contact your previous employer(s)?
Yes
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Reference 1
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Reference 3
AUTHORIZATION TO RELEASE INFORMATION Having made application for a position with Tolowa Dee-ni’ Nation / Lucky 7 Casino (TDN / L7C), I wish them to be informed as to my previous record and character, to determine my qualifications and suitability for the position. For this specific purpose, I hereby authorize the release and full disclosure of any and all information that you may have concerning me, including information of a confidential or privileged nature. Such information is to be released to any duly authorized agent of TDN / L7C, upon presentation of this waiver, or a photocopy of this waiver, whether in person, by mail, fax, or other method of conveyance. This release is valid for a period of six (6) months from the date of my signature. A photocopy of this waiver is to be considered as valid as an original of my signature. Examples of types of information I am requesting that you provide include, but are limited to: Dates of employment, job title, dependability, honesty, attitude towards the job, interactions with fellow employees, reason for leaving, education records, and/or other such information you may have concerning my qualifications and suitability. I hereby release you as the custodian of such record, and any law enforcement agency, criminal justice agency, school, college, university, or other educational institution, including officers, agents, employees, related personnel, both individually and collectively, from any and all liability for damage for whatever kind, which may at any time result to me, my heirs, family or associates, because of compliance with this authorization and request to release information, or any attempt to comply with it.
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