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  • 1Application
  • 2Application (cont'd)
  • 3Testing
  • 4Background Check
  • 5Consumer Reports

We are an equal opportunity employer and do not unlawfully discriminate in employment. No question on this application is used for the purpose of limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Equal access to employment, services, and programs is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify Human Resources.

Employment History: Please provide all employment information for your past three employers starting with the most recent.

Educational History: List school name and location, years completed, course of study, and any degrees earned:

References: List three references, including names, telephone numbers, and years known (do not include relatives or employers):

I hereby authorize QUALITY BY DESIGN to contact, obtain, and verify the accuracy of information contained in this application from all previous employers, educational institutions, and references. I also hereby release from liability the potential employer and its representatives for seeking, gathering, and using such information to make employment decisions and all other persons or organizations for providing such information.

I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered.

If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either I or QUALITY BY DESIGN can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law.

I understand that it is the policy of QUALITY BY DESIGN not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that person’s need for a reasonable accommodation as required by the Americans with Disabilities Act (ADA).

I also understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment.

I represent and warrant that I have read and fully understand the foregoing, and that I seek employment under these conditions.

I understand that submission to testing for the presence of drugs and alcohol is a condition of employment with Quality By Design, Inc. I further understand that:

  1. if I refuse to take the test,
  2. if I refuse to authorize release of the test results to Quality By Design, Inc., or
  3. if the test(s) establish a violation of Quality By Design, Inc policies concerning drug and alcohol use

May lead to disciplinary action up to and including discharge.

In addition, if I am injured on the job and test positive, I will forfeit my medical and indemnity benefits under Florida’s Worker’s Compensation Act upon exhaustion of the procedures in Florida Statutes 140.12 (5).

By placing my initials in the blanks below, and by signing and dating this form, I consent to take the test(s) and authorize release of any test results to Quality By Design, Inc. I understand that I may be placed on temporary leave of absence pending results of said test(s). I understand that should my test(s) results be confirmed positive, flagged as suspicious or diluted, I will be subject to disciplinary action up to and including discharge.

By signing this form, I herby release to Quality By Design, Inc. the results of the test(s) to which I have consented. I further authorize Quality By Design, Inc. to discuss the results with the medical personnel/physician collecting the specimen, the testing facility, its directors, officers, agents and employees responsible for administering the aforementioned test(s) or evaluating the results thereof and any of them herein and to use the test results as a defense to any legal action to which I am a party.

I further release any testing facility or any physicians who have tested me from any liability arising from a release of any and all results, written reports, medical records, and data concerning my test(s) to the appropriate Company officials.

I agree to take the following test(s) and to have the results released to Quality By Design, Inc.

I hereby REFUSE TO CONSENT to testing for the presence of drugs and/or alcohol:

NOTICE: QUALITY BY DESIGN will not discriminate against the applicant or employee or otherwise misuse the information, as provided by any applicable federal or state equal opportunity laws or regulations.

Please complete all sections of this form. All information collected on this form is confidential. Attach a copy of photo identification (driver’s license, passport, etc.).

I hereby authorize QUALITY BY DESIGN, Inc. to conduct a post-offer background check.

TO: Brown & Brown
ATTN: Terri Hendrickson
FAX: 1-866-610-3794

FROM: Quality By Design, Inc
FAX: 352-483-2984

Dear Quality By Design, Inc.

Consumer reports may be obtained as part of Quality By Design, Inc evaluation of my job application/employment.

The report may be procured by Brown & Brown and may include my driving record, as assessment of my insurability under Quality By Design, Inc, insurance coverage, or other consumer reports.

By signing this disclosure, I hereby authorize Quality By Design, Inc. to procure such reports and additional reports about me from time to time, as it deems appropriate, to evaluate my insurability, or for other permissible purposes.