Job Application

Job Application Personal Information _________________________________________________________________

__________________________

Full Name (Last, First, Middle)

Social Security Number

___________________

__________________

__________________

Home Phone

Cell Phone

Work Phone

____________________________ DL#

__________________________________ e-mail

______________ State

Current Address: ________________________________ Street / P.O. Box

___________________ _____ _________ ____________ City

State

Zip Code

From-To (dates)

List prior addresses for the last 7 years: Previous Address: ________________________________ Street / P.O. Box

___________________ _____ _________ ____________ City

Previous Address: ________________________________ Street / P.O. Box

State

Street / P.O. Box

From-To (dates)

___________________ _____ _________ ____________ City

Previous Address: ________________________________

Zip Code

State

Zip Code

From-To (dates)

___________________ _____ _________ ____________ City

State

Zip Code

From-To (dates)

Are you a citizen of the United States? __________ If no, are you authorized to work in the United States? ___________ What date are you available for employment? _____________________________________________________________ Have you ever applied for a position at Interactions? ___________________

If yes, when? ______________________

Have you been convicted of a felony, misdemeanor, or other crime in the past 7 years? _________ If yes, explain:

____________________________________________________________________________________

__________________________________________________________________________________________________ __________________________________________________________________________________________________ (Conviction will not necessarily disqualify you from employment.)

Education High School: Name/Location of School

Received : _____Diploma _____None _____Other (specify)______________ _____________

College, University, or Professional School: Name of School

Location

Dates of Attendance (Month/Year)

From

proprietary and confidential

To

Credit Hours Earned Qtr Sem

Major/Minor Course of Study

Type of Degree Earned

Job Application Employment History Give past employment record as completely as possible starting with latest employer. Employer name, address and Date from telephone number

Full Time or Part Time Employer name, address and Date from telephone number

Full Time or Part Time Employer name, address and Date from telephone number

Full Time or Part Time Employer name, address and Date from telephone number

Full Time or Part Time Employer name, address and Date from telephone number

Full Time or Part Time

Date to

Position/Duties

Salary

Name of your immediate supervisor

Date to

Position/Duties

Salary

Name of your immediate supervisor

Date to

Position/Duties

Salary

Name of your immediate supervisor

Date to

Position/Duties

Salary

Name of your immediate supervisor

Date to

Position/Duties

Salary

Name of your immediate supervisor

Reason for leaving

Reason for leaving

Reason for leaving

Reason for leaving

Reason for leaving

Professional References Name

1. 2. proprietary and confidential Revised 4/30/07

Occupation

Phone Number

Years Known

Relationship

Job Application 3.

Verification and Signature All of the information provided by me on this application, my personal resume, and any other supplementary materials, is true and correct. I authorize Interactions to verify the information provided by me and to contact any reference, employer, school, or educational institution listed by me. •

I understand that receipt of this application by Interactions does not mean that I have been hired or employed by Interactions. I understand that this application is not a contract of employment. If hired, I understand that the employment is “at will” and that the employment may be terminated by Interactions or by me at any time for any reason.

•

I understand that a comprehensive background investigation may be conducted as part of the employment process. I authorize Interactions to contact former employers, schools, and references listed on this application. I hereby release Interactions from any and all liability in connection with the furnishing of this information to Interactions.

•

I understand that if offered a position with Interactions, I may be required to submit to a preemployment test for illegal drug use or to submit to a test for illegal drug use at any other time during my employment. I understand that unsatisfactory results from, refusal to cooperate with, or any attempt to affect the results of a test for illegal drug use may result in disqualification from consideration for employment, the withdrawal of any employment offer, or termination of employment if already employed.

•

I UNDERSTAND THAT FALSIFICATION, MISREPRESENTATION, OR OMISSION OF INFORMATION ON THIS APPLICATION FOR EMPLOYMENT OR ON ANY OTHER EMPLOYMENT FORM, SHALL BE GROUNDS FOR DISQUALIFICATION FROM CONSIDERATION FOR EPLOYMENT, WITHDRAWAL OF ANY EMPLOYMENT OFFER, OR IMMEDIATE TERMINATION, REGARDLESS OF WHEN SUCH FALSIFICATION, MISREPRESENTATION, OR OMISSION IS DISCOVERED.

___________________________________________________________ Signature of Applicant

proprietary and confidential Revised 4/30/07

__________________________ Date