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All persons, including minorities, disabled persons, and those who are pursuing employment and/or social rehabilitation, are encouraged to complete the following form.  We attempt to ensure that employment decisions are based mostly on past employment, not disability or other illegal disqualifiers.  We are an equal opportunity employer.  All information is required for employment consideration.  Please do not provide information that cannot lawfully be asked of residents of your area.

Please note which of the following employment opportunities you are considering. 

Data entry Shipping Clerk Customer Service Representative
Inventory Control Clerk Software Developer Sales
Delivery Driver Telephone Sales Representative Human Resources Coordinator
On-Site Security Coordinator Charity Fundraising Coordinator    

About you:

First name
Last name
Address
City
State
ZIP code
Country
Phone number
E-mail address
Social Security number --
Driver's license number State:
Birthdate
Do you have a flat-rate,
per-month long distance plan?

Are you willing to work:

Part-time Days Weekends
Full-time Evenings Overtime
    Nights    

 

Other important information
NOTE: If your jurisdiction prohibits any of these questions, please select "Not required by law to reply" and leave the other fields blank or select "Not Applicable".

Have you ever been convicted of unlawful criminal conduct? What offense? Type of crime:
Date of conviction

 

Have you ever served in the Military? Branch: Admission date:
Discharge date:

Education

Type Name of school Degree earned Location city & state Dates attended Date graduated
High School through
College through
Other through

Employment

Current/Most recent

Job title
Company
Address
City
State
ZIP code
Phone number
Supervisor's name
Salary Per
Dates worked , through ,  
Reason for leaving

Next most recent employment

Job title
Company
Address
City
State
ZIP code
Phone number
Supervisor's name
Salary Per
Dates worked , through ,
Reason for leaving

Next most recent employment

Job title
Company
Address
City
State
ZIP code
Phone number
Supervisor's name
Salary Per
Dates worked , through ,
Reason for leaving

Preferred payment method (optional)

If you wish, you may indicate how you would like to be paid. 
No funds will be withdrawn from your accounts.
   
Bank account
Paypal
Cashier's check/money order
 
Bank
Bank account routing number
Bank account number
Type of account
Paypal e-mail address

Scroll down in the following text box.  Do not edit, add, remove, change or otherwise modify this box or its contents.

Notes:

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