Personal Information First Name: Middle Initial: Last Name: Current Address: Apartment/Suite: City: State: MN IA Zip Code: Phone Number: Best Time to Call: How did you hear about us? Newspaper Ad Friend Craigslist Newspaper/Friend name: Preferred Office: Burnsville Fridley Ames Position Desired: -- Select Position Sales Agent Customer Service Inbound Representative When can you start? Desired Salary: Full/Part Time: Full Time Part Time How many hours per week? Can you work overtime? Yes No Have you applied with us before? Yes No If so, when? Do you have a valid driver's license and dependable transport to work? Yes No If you are a minor, can you produce the work certificate necessary to obtain employment? N/A Yes No Are you able, at the time of employment, to submit verification of your legal right to work in the US? Yes No Have you ever been convicted of a felony or a misdemeanor? (Do not include minor traffic violations, speeding, seatbelt, etc.) A conviction record will not necessarily be a bar to employment. Note: This questions does not apply to convictions which have been expunged, sealed, pardoned or otherwise exonerated. A conviction record will not necessarily be a bar to employment. Yes No If yes, please describe fully the criminal conviction(s), listing the nature of the offense(s) and your rehabilitation since the conviction(s.) Education High School #1: Highest Grade Completed: 12 11 10 9 GED Major Area of Study: High School #2: Highest Grade Completed: 12 11 10 9 GED Major Area of Study: College #1: Highest Grade Completed: Freshman Sophomore Junior Senior Major Area of Study: College #2: Highest Grade Completed: Freshman Sophomore Junior Senior Major Area of Study: Describe any specialized skills you have: Work Experience Employer #1 Name: Address: Phone: Salary: Position: Supervisor: Reason for Leaving: Start Date: End Date: Employer #2 Name: Address: Phone: Salary: Position: Supervisor: Reason for Leaving: Start Date: End Date: Employer #3 Name: Address: Phone: Salary: Position: Supervisor: Reason for Leaving: Start Date: End Date: Employer #4 Name: Address: Phone: Salary: Position: Supervisor: Reason for Leaving: Start Date: End Date: May we contact your current or previous employers? If not, please explain. References Reference #1 Name and Position: Phone: Company: Reference #2 Name and Position: Phone: Company: Reference #3 Name and Position: Phone: Company: Applicant Certification Please Read Carefully I understand that this application is not a contract, offer or promise of employment. I acknowledge that employment with the company is on an employment at will basis. This means that my employment with the company can be terminated at any time, with or without cause or advance notice and acceptance of employment is not a contract of employment for any specified time. Similarly I am free to terminate my employment with the company at any time for any reason. This at-will provision may be modified or waived only in a written agreement signed by the company's president and I. I further understand that I am responsible for being familiar with the Company's policies, rules and regulations, and I understand that the company has complete discretion to modify it's policies, rules, regulations and practices at any time, to the extent permitted by federal, state and local law, except that it will not modify it's policy of employment at will. By my continued employment with the Company, I consent to any such changes. I certify that the above information is complete and accurate to the best of my knowledge. I understand that any falsification, misrepresentation or omission of information on this form or relating to the application of employment may result in my denial of employment, or if employed, my immediate dismissal. I hereby authorize the Company or its agents to confirm all statements contained in this application and/or resume to the extent permitted by federal, state or local law and I agree to complete any requisite authorization forms. I release all parties from any liability arising out of this provision and the use of such information.