Reseller Employment Application

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/


Inside Reseller Employment Application