First Name*

Last Name*

Email Address*

Phone Number*

Street Address*

Apartment

City*

State*

Zip Code*

Birthday*

What are you applying for?

Full Time
Part Time

When are you available to start work?*

Have you ever done sales before?

Yes
No
Some

If Yes ~ Where*

Are you currently employed?

Yes
No

If Yes ~ Name of Company*

May we contact your current employer?

Yes
No

Do you have a valid driver's license?

Yes
No

Do you have reliable transportation?

Yes
No

Have you been convicted of any crime in the last 7 years?

Yes
No

If Yes ~ What?*

Education

GED
High School Diploma
College

Please list 2 personal references and their contact information*

Current or Most Recent Employer*

Supervisor Name*

Telephone Number*

Employment Dates ~ End to Beginning*

Reason for Leaving*

Duties Performed*

Have you ever been in the Armed Forces?

Yes
No

Are you currently in the National Guard or Reserve?

Yes
No

Please list any skills or special interest that may help you succeed in sales with PAontheweb.com*

Please tell us days and times you are available for an interview within the next two weeks*

Signature Certification

By re-typing your name in the block below and submitting this form you are certifying that the information you have provided is true and complete.

I understand that any false information is grounds for not hiring me or immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.*