CRIMINAL AND EMPLOYMENT BACKGROUND QUESTIONNAIRE

Actualizó: Analista de Gestión de Procesos, Eduardo Yduarte / Aprobó: Gerente de Reclutamiento Operativo, Vanessa Zuno / Vr04 / Última Revisión 21Feb22
Clasificación: Restringida

Please complete the following information

NAME: EMP. No. / FOLIO No.:

POSITION APPLYING FOR:

Information relating to employments in EUA

NAME:
HOME PHONE NUMBER: SOCIAL SECURITY NO.: DATE OF BIRTH:
ADDRESS (no po.boxes):
(City) (State) (Zip Code)

I have been arrested and / or have pending charges or warrants? If answer is YES, provide detail below.

List any and all of your convictions and pending charges below if it occurred within the last seven years anywhere (either administrative or criminal). If you have been
arrested in more than one state, please identify the states, country and dates. If you do not recall all of your convictions, then you MUST indicate this below. Add pertinent
facts and circumstances as necessary. An official criminal background check will be conducted that will reveal your arrest record. The above information will facilitate the
processing and evaluation of your status in the company. You are not automatically disqualified of any criminal conviction.

Convictions and / or Pending Charges:

Conviction Date / Arrest Date Offense (Detail Information) Name and Location of Court Sentence and Date of / Disposition Status

The information I have provided on this document is accurate to the best of my knowledge under statement of truth. I authorize the employer to share criminal background
results with third party companies for whom I will be placed to work as a representative.

FINGER PRINT

APPLICANT SIGNATURE

DATE