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:

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: