Employment Opportunities

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Social Security Number*

Email*

Home Telephone*

Cell Phone

Have you ever been convicted of a felony or are there any felony charges pending against you?*

Yes
No

If yes, please state date, place and nature of conviction (a conviction does not constitue an automatic bar to employment.)

Are you able to perform all of the essential functions and duties required of the position which you are applying, with or without reasonable accomodation?*

Yes
No

If no, how would you perform these essential functions and duties, and with what accomodations?

Are you subject to any City / Location tax?*

Yes
No

Name of City / Locality:

If under the age of 18, please state your age:

If under 18, please provide work permit.

Name:

Relationship:

Daytime Telephone:

Cell Phone:

Evening Telephone:

Employment history:

Start with present employer and list all previous employment.

Dates (Month & Year) From / To:

Employer's Name, address and phone number:

Supervisor's Name & Title:

Position:

Reason for leaving:

Resigned
Discharge
Laid Off
Other

(Please explain):

Dates (Month & Year) From / To:

Supervisor's Name & Title:

Employer's Name, address and phone number:

Position:

Reason for leaving:

Resigned
Discharge
Laid Off
Other

(Please explain):

Dates (Month & Year) From / To:

Supervisor's Name & Title:

Employer's Name, address and phone number:

Position:

Reason for leaving:

Resigned
Discharge
Laid Off
Other

(Please explain):

Dates (Month & Year) From / To:

Supervisor's Name & Title:

Employer's Name, address and phone number:

Position:

Reason for leaving:

Resigned
Discharge
Laid Off
Other

(Please explain):

Please indicate which employer(s) you have listed that you do not wish us to contact:

Education

High School:

Address:

Grade of Completion:

College or Grade School:

Address:

Grade of Completion:

List any special license or certification:

Please read carefully before signing and submitting:

I certify that all statements made on this application form are correct and I understand that any false statements will be sufficient cause for rejection of my application or sufficient cause for discharge if I am hired. I grant the company permission to investigate any of the information given on this application form. I understand that the use of this form does not indicate that there are any positions open and does not in any way obligate this company. Further, I understand and agree that if I an hired by this company, unless specifically set forth in writing to the contrary and signed by the President, my employment will be for no definite period, and may, regardless of the date of payment of my wages or salary, be terminated at any time for any reason at the will of the company without any previous Notice. AccessPoint is an equal opportunity employer. It is our policy that all applicats be considered solely on the basis of qualifications and ability, without regard to race, religion, color, sex, age, national origin, disability, height, weight, marital status or veteran status. I agree that any claim or lawsuit arising form or related to my employment with accesspoint or any of its subsidiaries must be filed no more than six (6) months from the date of the employment action that is the subject of the claim or lawsuit. I hereby waive any statute of limitations to the contrary.

Applicant's Name:*

Date:*

Employment history:

Education

Please read carefully before signing and submitting:

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