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: