InSite Support Services, Inc.
Employment Application

Personal Data

Are you 16 years of age or older? Yes No

Were you previously employed with InSite? Yes No

Have you had any convictions other than traffic violations? Yes No

If "yes", please explain

How were you referred to InSite Support Services Inc.? Please click the number of the most appropriate response

Position Preferences

Schedule Availability (Please list all days / hours you are willing and able to work.)

Education and Experience

High School

School Name:

City and State:

Diploma or # of Years Completed:

College

School Name:

City and State:

Degree or # of Years Completed:

Major or Subject: Grade Point Average:

List any certificates earned or in progress, any additional languages, and/or any additional training programs or experience relevant to the position, which is not included in your formal education.

List any Professional Affiliations to which you belong (please do not list activities which would indicate age, sex, color, race, creed, national origin, religion, marital status, sexual orientation, political belief, or disability):

Employment History: List your current or most recent employment first. Include work related internships, military and volunteer work.

Current Employer: City, State:

Tel. #: Position Title/Duties:

Supervisor's Name/Title:

Reason for Leaving:

Dates of Employment: From: To: Salary:

May We Contact Your Employer: Yes No

Previous Employer: City, State:

Tel. #: Position Title/Duties:

Supervisor's Name/Title:

Reason for Leaving:

Dates of Employment: From: To: Salary:

Previous Employer: City, State:

Tel. #: Position Title/Duties:

Supervisor's Name/Title:

Reason for Leaving:

Dates of Employment: From: To: Salary:

Previous Employer: City, State:

Tel. #: Position Title/Duties:

Supervisor's Name/Title:

Reason for Leaving:

Dates of Employment: From: To: Salary:

Releases and Applicant's Signature

In connection with my application for employment and as a condition of continuing employment, I understand that investigative background inquiries may be made on me including previous employers, schools, consumer credit, criminal convictions, motor vehicle, and other reports. These reports will include information as to my character, work habits, performance, education, compensation, and experience along with reasons for termination of employment from previous employers. Furthermore, I understand that the company may be requesting information from various federal, state, and other agencies which maintain records concerning my past activities relating to my driving, credit, criminal, civil, and other experiences as well as claims involving me in the files of insurance companies. I authorize without reservation, any party or agency contacted to furnish the above mentioned information and release all parties involved from liability and responsibility for doing so. I hereby consent to obtaining the above information from InSite Support Services Inc. and/or any of their agents. This authorization and consent shall be valid in original, fax, or copy form.

Please initial:

I hereby certify that all of the information provided in this application is true and accurate: