RESELLER APPLICATION
Applications are considered without regard to race, color, religion, sex, national origin, age, marital or veteran status, or the presence of a non-job-related medical condition or handicap.
PERSONAL INFORMATION:
Date _________________ Territory Applied For _________________ Start Date _______________________
(__) Full Time (__) Part Time (__) Temporary
Referral Source ___________________________________________
Name: _________________________ D.O.B.: _________________
Business Name: ___________________ Form of Entity: ______________
Street Address: ___________________________ Phone: _____________
City/State/Zip: _____________________________ SSN: _____________
Are you a U.S. citizen? (__) Yes (__) No If no, what is your citizenship/residency status: ___________________________________
Have you ever been convicted of or charged with a felony or misdemeanor: (__) Yes (__) No If yes, please explain details in full, including dates, details of offense(s) charged, jurisdiction and disposition of case: _________________________________________________________
Have you, or any person or entity with whom you have been associated with, filed for bankruptcy, been declared bankrupt or insolvent or been the subject of any receivorship proceedings within the last 7 years?
(__) Yes (__) No
If Yes, please provide full details, including dates, places, amounts involved and disposition: ______________________________________________
EDUCATION:
Schools/Colleges Attended: # Years Year Grad Degree
________________________________ ______ _______ ______
________________________________ ______ _______ ______
________________________________ ______ _______ ______
EMPLOYMENT/WORK EXPERIENCE: Start with your present or most recent position. Include military service assignments and volunteer activities. Exclude organization names that indicate race, color, religion, sex or national origin.
Employer: ________________________________________________
Job Title: ______________________ Supervisor: _________________
Street Address: ____________________________________________
City/State/Zip: __________________________ Phone: _____________
Describe Duties/Responsibilities/Accomplishments:
__________________________________________________________
__________________________________________________________
__________________________________________________________
Reason for Leaving: __________________________________________
Dates of Employment (Month/Year): From ________ To ____________
Employer:_________________________________________________
Job Title: __________________ Supervisor: ____________________
Street Address: ____________________________________________
City/State/Zip: ___________________________ Phone: ___________
Describe Duties/Responsibilities/Accomplishments:
___________________________________________________________
___________________________________________________________
___________________________________________________________
Reason for Leaving: ___________________________________________
Dates of Employment (Month/Year): From _______ To ___________
Employer:_________________________________________________
Job Title: __________________________ Supervisor: ______________
Street Address: _____________________________________________
City/State/Zip: _________________________ Phone: _____________
Describe Duties/Responsibilities/Accomplishments:
_________________________________________________________
_________________________________________________________
_________________________________________________________
Reason for Leaving: _________________________________________
Dates of Employment (Month/Year): From _______ To ____________
BUSINESS REFERENCES: Please provide individual and company names, position, addresses and phone numbers for 3 business references.
Name: _______________________ Company: __________________
Street Address: _________________________ Position: __________
City/State/Zip: _________________________ Phone: ___________
Name: _______________________ Company: __________________
Street Address: _________________________ Position: __________
City/State/Zip: ___________________________ Phone: ___________
Name: ________________________ Company: _________________
Street Address: __________________________ Position: ___________
City/State/Zip: ___________________________ Phone: ___________
PERSONAL REFERENCES: Please provide names, addresses, phone numbers, relationship and how long known for 3 personal references.
Name: _________________________ Relationship: _______________
Street Address: __________________________ How long: __________
City/State/Zip: ___________________________ Phone: ___________
Name: __________________________ Relationship: ______________
Street Address: __________________________ How long: __________
City/State/Zip: ___________________________ Phone: ___________
Name: ___________________________ Relationship: _____________
Street Address: ___________________________ How long: _________
City/State/Zip: ____________________________ Phone: ___________
SPECIAL SKILLS: Describe any special skills or qualifications for this work: ____________________________________________________
_________________________________________________________
__________________________________________________________
I CERTIFY that the above answers are true and complete to the best of my knowledge. I authorize ________________________________, to investigate any statement contained in this application, and to obtain a credit report on me (and my company if this application is for reselling by a company) as necessary to determine my qualifications. I understand that this application is not and is not intended to be any kind of contract or agreement. In the event of employment, I understand that any false or misleading information given in my application, correspondence, discussions or interview may result in immediate termination. I understand also, that I am required to abide by all rules, regulations and policies of __________________________.
Signed: _______________________ Date: ____________________
FOR ________________ USE ONLY: __________________
Arrange Interview: (__) Yes (__) No Date: ______________
Place: __________________________________________________
Remarks: _______________________________________________
_______________________________________________________
_______________________________________________________
Approved: (__) Yes (__) No Date: ____________________
By: ______________________________________________
State Specific Application Forms
—-For State Specific Application Forms you can download in Word Format go to
http://www.uslegalforms.com/applications/