Application for Employment

Starting with your most recent employer, provide the following information:

List three references that are not related to you and are not previous supervisors.

Ethnicity

Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.

Race

Caucasian (Not Hispanic or Latino) – A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.

American Indian or Alaskan Native (Not Hispanic or Latino) – A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment.

Asian (Not Hispanic or Latino) – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Black or African American (Not Hispanic or Latino) – A person having origins in any of the Black racial groups of Africa.

Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) – A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

Two or More Races (not Hispanic or Latino) – All persons who identify with more than one of the above five races.

I hereby authorize Stoneridge, Inc., Control Devices Division (hereinafter referred to as Control Devices) and/or any entity directed by Control Devices to obtain a consumer report for employment purposes. A “consumer report” includes any information as to my credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living. I understand this consumer report may include inquiries regarding my work history; personal financial status and credit history; court records, including criminal conviction record, as permitted by law, driving history; and references obtained from professional and personal associates. Reports containing credit and financial information will only be obtained for positions requiring access to Control Devices finances (i.e. purchasing, accounting, etc.) I further understand and agree that a consumer report may be obtained at any time, and any number of times, as Control Devices in its sole discretion determines is necessary before, during or after my employment.

I hereby authorize all previous employers, educational institutions, consumer reporting agencies and other persons or entities having information about me to provide such information to Control Devices or other entity that obtains information for Control Devices. I further fully release Control Devices, its employees, officers, directors, agents, successors and assigns, and all other parties involved in this background investigation, including but not limited to investigators, credit agencies and those companies or individuals who provide information to Control Devices concerning me, from any claims or actions for any liability whatsoever related to the process or results of the background investigation.

I understand I can receive a free copy of any credit report requested by Control Devices about me at the same time the report is provided to Control Devices (check box below if copy desired). I understand that an offer of employment is contingent upon the outcome of my background check, and that this Disclosure Authorization is not an offer for employment by Control Devices or a contract for employment with Hi-Stat. I further understand Control Devices operates under an AT-WILL EMPLOYMENT POLICY and this Authorization does not alter or affect that policy in any manner whatsoever.