PERSONAL INFORMATION

First Name
Middle Name
Last Name
Social Security Number (optional)
Email
Home Telephone
Cell Phone

Current Address

Street
City
State
Zip Code
Position Applied For & Desired Wage

GENERAL INFORMATION

Are you age 18 or older?
Are you a U.S. Citizen?
Do you have a legal right to work and remain in the U.S.?
Note: Individuals with work authorization based on non-immigrant visa status should advise type of visa when submitting
application.
Have you ever been discharged from any employment or asked to resign?
If Yes, please explain.

EDUCATION/TRAINING/QUALIFICATIONS

High School
Name & Location
Course of Study
Highest Year Completed
Graduated?
Degree
College
Name & Location
Course of Study
Highest Year Completed
Graduated?
Degree
Graduate School
Name & Location
Course of Study
Highest Year Completed
Graduated?
Degree
Business, Trade, Other
Name & Location
Course of Study
Highest Year Completed
Graduated?
Degree
Certifications
Certifications if any

PREVIOUS WORK EXPERIENCE

Start with present or most recent employer. Please give accurate, complete full-time and part-time employment. Include any job-related military service and volunteer activities. You may exclude organizations that indicate race, color, religion, gender, national origin, disabilities, or other protected status. Additional pages may be used if needed. DO NOT WRITE “SEE RESUME.”

1

Present or last Company name:
Telephone:
Address:
Date of Employment
From:
To:
Job Title
Supervisor's Name:
Supervisor's Number:
Pay Rate
Briefly Describe your Duties:
Reason for Leaving:

2

Company name:
Telephone:
Address:
Date of Employment
From:
To:
Job Title
Supervisor's Name:
Supervisor's Number:
Pay Rate
Briefly Describe your Duties:
Reason for Leaving:

3

Company name:
Telephone:
Address:
Date of Employment
From:
To:
Job Title
Supervisor's Name:
Supervisor's Number:
Pay Rate
Briefly Describe your Duties:
Reason for Leaving:

4

Company name:
Telephone:
Address:
Date of Employment
From:
To:
Job Title
Supervisor's Name:
Supervisor's Number:
Pay Rate
Briefly Describe your Duties:
Reason for Leaving:

We may contact the preceding list of employers unless you indicate those
you do not want us to contact.

PROFESSIONAL REFERENCES (DIRECT SUPERVISORS ONLY)

1

Name and Title:
Telephone:
Email:
Relationship:
Should we contact this person? If no, given reasons below
Give reasons:

2

Name and Title:
Telephone:
Email:
Relationship:
Should we contact this person? If no, given reasons below
Give reasons:

3

Name and Title:
Telephone:
Email:
Relationship:
Should we contact this person? If no, given reasons below
Give reasons:

APPLICANT ACKNOWLEDGEMENT AND AUTHORIZATION

Please read carefully before signing.

I certify that all answers given by me are true, accurate and complete; I understand that the falsification, misrepresentation or omission of fact on this application (or any other accompanying or required documents) will be cause for denial of employment or immediate termination of employment, regardless of when or how discovered.

I authorize the investigation of all statements and information contained in this application. I release from all liability anyone
supplying such information and I also release the employer from all liability that might result from making an investigation.

If hired, I agree to conform to all of 1st Choice, LLC’s policies and procedures, and understand that, if employed, my employment is .at-will. and may be terminated with or without cause, and with or without notice, at any time, at the option of either the company or me, I further understand that no representation, whether oral or written by any representative or agent of the Company, at any time, can constitute a contract of employment. No representative or agent of the company has the authority to enter into any agreement for employment for any specified period of time or to make any change in any policy, procedure, benefit or other term or condition of employment other than in a document signed by the President & CEO, or to make any agreement contrary to the foregoing.

I hereby authorize any and all schools, former employers, references, courts and any others who have information about me to
provide such information to 1st Choice, LLC and/or any of its representatives, agents or vendors and I release all
parties involved from any and all liability for any and all damage that may result from providing such information. By signing below I acknowledge that I have read, understood and agree to the above statements.

Applicant Signature (print your name)
Date:

1st Choice, LLC is proud to be an equal opportunity employer. All qualified applicants will receive
consideration without regard to race, color, religion, gender, national origin, age, disability, veteran status or any other status protected by law.

AUTHORIZATION

Authorization:

By signing below, you authorize: (a) General Information Services, Inc. ("GIS") to request information about you from any public or private information source; (b) anyone to provide information about you to GIS; (c) GIS to provide us 1st Choice one or more reports based on that information; and (d) us to share those reports with others for legitimate business purposes related to your employment. GIS may investigate your education, work history, professional licenses and credentials, references, address history, social security number validity, right to work, criminal record, lawsuits, driving record, credit history, and any other information with public or private information sources. You acknowledge that a fax, image, or copy of this authorization is as valid as the original. You make this authorization to be valid for as long as you are an applicant or employee with us.

The Consumer Financial Protection Bureau's "Summary of Your Rights under the Fair Credit Reporting Act" is attached to this authorization. If you are a New York applicant, a copy of New York's law on the use of criminal records is attached. By signing below, you acknowledge receipt of these documents.

Personal Information:

Please print the information requested below to identify yourself for GIS.

First Name:
Middle Name:
Last Name:
Other Names Used:

1

Current and Former Addresses:
Current Address (Street):
From (M/Y)
To (M/Y):
City/State/Zip:

2

Street:
From (M/Y)
To (M/Y):
City/State/Zip:

3

Street:
From (M/Y)
To (M/Y):
City/State/Zip:

Some government agencies and other information sources require the following information when checking for records. GIS will not use it for any other purposes.

Date of Birth:
Social Security Number:
Driver's License Number and State:
Name as it appears on License:

Report Copy:

: If you are applying for a job or live in California, Minnesota, or Oklahoma, you may request a copy of the report by checking this box:

Signature (Print your name:)
Date:

DISCLOSURE

We, 1st Choice, will obtain one or more consumer reports or investigative consumer reports (or both) about you for employment purposes. These purposes may include hiring, contract, assignment, promotion, re-assignment, and termination. The reports will include information about your character, general reputation, personal characteristics, and mode of living.

We will obtain these reports through a consumer reporting agency. Our consumer reporting agency is General Information Services, Inc. GIS's address is P.O.Box 353, Chapin, SC 29036. GIS's telephone number is (866) 265-4917. GIS's website is at www.geninfo.com, where you can find information about whether GIS's international privacy practices.

To prepare the reports, GIS may investigate your education, work history, professional licenses and credentials, references, address history, social security number validity, right to work, criminal record, lawsuits, driving record, credit history, and any other information with public or private information sources.

You may obtain a copy of any report that GIS provides and GIS's file about you (in person, by mail, or by phone) by providing identification to GIS. If you do, GIS will provide you help to understand the files, including trained personnel and an explanation of any codes. Another person may accompany you by providing identification.

If GIS obtains any information by interview, you have the right to obtain a complete and accurate disclosure of the scope and nature of the investigation performed.

Please sign below to acknowledge your receipt of this disclosure.

Signature (Print your name:)
Date: