PLEASE COMPLETE ENTIRE APPLICATION, USING DARK INK OR A TYPEWRITER TO ENSURE PROCESSING (If entering on-line, use 8 pt. Type – Arial font)

(Print) Last Name / First Name / Middle Initial / Social Security No. / Today’s Date
List All Your Previous Names Under Which Employment or Education May Be Verified /

E-mail Address

Current Address (Use Complete Mailing Address with County & Zip Code) /
Phone No. with Area Code
Permanent Address (with County) / Phone No. with Area Code

Previous Address (with County)

C A R E E R

Position/Type of Work Desired
/ Please Put an “X” in a Box Below
Full Time Part Time Shift Work Temporary Summer
How Did You Hear of This Position/Company? /
Date Available for Employment
Do you have any relevant experience for the job you applying for? If so please list.

E D U C A T I O N (Must be filled out for consideration – do not refer to resume)

Type of School / Name of School (with City/State) / Major Field
of Study / Dates Attended (From Mo./Yr. To Mo./Yr.) / Years (Completed) / Degree (Including Mo./Yr. Granted or Expected)
High School
College or University
Graduate or other Formal Education
Scholastic Honors/Scholarships
(Indicate at Right)
A D D I T I O N A L D A T A

Have You Been Convicted of any Crime other than a Minor Traffic Violation? A conviction will not necessarily disqualify you.

/

Date(s)

/

Place(s)

/

Charge(s)

Yes No
Do You Have the Right to Work in the U.S.? (Please check the correct box at the right) Yes No
What computer programs or software are you familiar with?
Please provide any additional information such as special skills, training, management experience, equipment operation, or qualifications you feel will be helpful to us in considering your application:

E M P L O Y M E N T H I S T O R Y (Must be filled out for consideration – do not refer to resume)

Are you employed now? (Indicate at Right) / Yes No
May We Contact Your Present Employer? (Indicate at Right) / Yes No
If presently employed, why do you desire to change your position?
Please give complete & detailed information regarding your present & former employment (exclude military service) to ensure application processing. Indicate with an “X” whether the position was full-time, part-time, or summer employment.
From / To / Full-time / Part-time / Summer / Nature of Work & Job Title / Starting Salary/Wage
(Hrly or Annual) / Ending Salary/Wage (Hrly or Annual) / Reason for Leaving or Seeking New Employment
Employer
City/State
Supervisor’s Name & Phone No.
Employer
City/State
Supervisor’s Name & Phone No.
Employer
City/State
Supervisor’s Name & Phone No.
Employer
City/State
Supervisor’s Name & Phone No.

M I L I T A R Y – Check box if military is not applicable

Period of Active Duty (Mo./Yr. To Mo./Yr.) / Branch of Service / Highest Rank / Discharge Status / Describe Principle Duties Performed

G E N E R A L

Have you previously applied, interviewed, or been employed by QPSI? (Check the appropriate box below & then, if “Yes”, provide us with specific information including dates & locations of where you applied, interviewed, or were employed.
Yes No
Are you 18 years of age or older? / Do You Have a Valid Driver’s License? / State / License No.
Yes No
Preferred Salary / Minimum Salary

R E F E R E N C E S – Include two professional references & 1 personal reference - do not include Supervisors listed above or relatives.

Name & Title (if personal, indicate relationship) / Best way to reach each reference
(day/evening phone no., e-mail address, other) / Years known
(Please check this box to certify that all information given on this application is true & correct. DO NOT SUBMIT YOUR SHEET WITHOUT
CHECKING THIS BOX)
I certify that all information given on this application is true and correct. I understand that QPSI or any third-party investigation company retained by QPSI may make an investigation of my work & personal history and I authorize all persons, schools, companies, corporations, credit bureaus & law enforcement agencies to supply any information concerning my background and release them from any liability & responsibility rising from their doing so. And if hired, my employment would be “at will” which means I may be terminated at any time for any or no reason. Any change to the policies stated above must be in writing & signed by the CEO/ President and/or designee of the Company in order to be effective.
Applicant’s Signature / Date

This statement may be photocopied for background investigation. NOTE: Your application will be kept active for one year after submission.

Equal Opportunity:We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non-job-related medical condition or handicap, or any other legally protected status. We will give this application every consideration. However, in accepting it, the Company makes no commitment of employment to the applicant. This application will remain active for six months.

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