Declaration
1. I hereby authorize Jefferson Energy Cooperative, to whom this application is submitted to contact school, college, employment and all other sources for the purpose of investigating and verifying statements and references herein and I authorize the above sources to provide such information and release them from all liability in connection with providing to Jefferson Energy Cooperative job-related information concerning my education or employment.

2. I understand my application will be investigated. I warrant the foregoing to be a truthful and complete statement of fact. Furthermore, any untrue or misleading answer or concealment of any fact will constitute grounds for no further consideration of my application or immediate discharge at any time during my employment that such false statements become known.

3. I submit this application with the understanding that a drug screen is a condition to employment. I also understand that failure to consent to a screen for drugs will be considered a withdrawal of my employment application and that a negative drug screen is a requirement of employment. I authorize the drug testing facility to release the results of this drug screen to the authorized representative of Jefferson Energy.

4. I agree that if I am employed by Jefferson Energy Cooperative, during and after such employment, I will not disclose or otherwise use any proprietary or confidential information that comes into my possession during the course of such employment, whether with respect to products, customers, suppliers or otherwise.

5. I understand that my employment and compensation, regardless of the time or method of payment, can be terminated, with or without cause, at any time, at the option of either the company or me. I further understand that no personnel recruiter, interviewer, or representative of the company, other than the president or designated representative, has any authority to enter into any agreement for employment for any specified period of time or any agreement contrary to the foregoing, and if such agreement is made, it must be in writing.

Jefferson Energy Cooperative seeks to employ the best qualified personnel without regard to race, color, sex, age, religion, creed national origin, citizenship status, marital status, sexual orientation, genetic information, disability or protected veterans status or any other status protected by law. The Age Discrimination Act prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age. As an employer with an Affirmative Action Program, we comply with government regulations, including Affirmative Action responsibilities where they apply. The purpose of the Data Record is to comply with government record keeping, reporting, and other legal requirements. Periodic Reports are made to the government on the following information. The completion of this Data Record is optional. If you choose to volunteer the requested information, please note that all Data Records are kept in a Confidential File and are not a part of your Application for Employment or personnel file. Please note, your cooperation is voluntary. Inclusion or exclusion of any data will not affect any employment decision.

JEC is required to report to the federal government with respect to certain categories. To enable us to meet these government reporting regulations, we request that you complete this personal information data form. Information will be used solely for government reporting purposes and will be kept separate from your application. Any information that you choose to provide will not be considered by the company for employment purposes and will be treated as personal and confidential. Your decision to provide or not to provide the requested information will not subject you to any adverse treatment. Your voluntary cooperation is appreciated.

It is our company’s policy to perform employment background checks in connection with employment applications. In performing the background checks we may request a “consumer report” to learn information about you that may be used in making an employment decision. A “consumer report” is a report obtained from a consumer reporting agency (such as, but not limited to Merchants Credit Bureau, Equifax, Experian, TransUnion, or the agency who will obtain the information for us) that has a bearing on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics or mode of living. The report may include but is not limited to your credit report; educational information; criminal record; and motor vehicle driver’s license or driving record. If Jefferson Energy Cooperative requests an investigative consumer report, which would include personal interviews, you will receive a second notice indicating that the report has been requested no later than three days after the request is made to a consumer reporting agency. This additional notice, if issued, will advise you as to your further rights pertaining to investigative consumer reports. If any adverse action that is made with regard to your application or employment based entirely or in part on the information contained in a consumer report, you will be notified as to the basis of that decision and given a copy of the report as well as a summary of your applicable rights. If you have ever filed for bankruptcy such information may or may not be relevant for employment purposes but no employment decision will be based solely on this information. Your signature on our employment application or any other pre-employment forms authorizes us to obtain such a consumer report. Your signature indicates that you have carefully read and understand this notice and consent to the release of a consumer report or investigative consumer report to Jefferson Energy Cooperative for employment purposes at Jefferson Energy Cooperative’s discretion either in connection with your job application or in connection with any future decisions concerning your employment, promotion, reassignment or retention as an employee. Your signature reflects your understanding that such consent will remain in effect indefinitely until you revoke it in writing. You will not be considered for employment if you do not allow us to perform an employment background check.

We are a federal contractor or subcontractor required by law to provide equal employment opportunity to qualified people with disabilities. We are also required to measure our progress toward having at least 7% of our workforce be individuals with disabilities. To do this, we must ask applicants and employees if they have a disability or have ever had a disability. Because a person may become disabled at any time, we ask all of our employees to update their information at least every five years. Identifying yourself as an individual with a disability is voluntary, and we hope that you will choose to do so. Your answer will be maintained confidentially and not be seen by selecting officials or anyone else involved in making personnel decisions. Completing the form will not negatively impact you in any way, regardless of whether you have self-identified in the past. For more information about this form or the equal employment obligations of federal contractors under Section 503 of the Rehabilitation Act, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition. Disabilities include, but are not limited to:

• Autism
• Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, or HIV/AIDS
• Blind or low vision
• Cancer
• Cardiovascular or heart disease
• Celiac disease
• Cerebral palsy
• Deaf or hard of hearing
• Depression or anxiety
• Diabetes
• Epilepsy
• Gastrointestinal disorders, for example, Crohn's Disease, or irritable bowel syndrome
• Intellectual disability
• Missing limbs or partially missing limbs
• Nervous system condition for example, migraine headaches, Parkinson’s disease, or Multiple sclerosis (MS)
• Psychiatric condition, for example, bipolar disorder, schizophrenia, PTSD, or major depression