bluespace Employment Application

First Name: *

Middle Name:

Last Name: *

Telephone Number:

Alternative Number:

Email Address: *

Present Address:

City:

State:

Zip Code:

Permanent Address:

City:

State:

Zip Code:

Were you ever employed by us:

Yes No

If so, please provide period(s) employed and position(s) held:

How did you learn about us?

Position or type of Work Desired:

(First Choice)

Second Choice:

Work schedule desired:

Full Time Part Time Temporary

Date available to begin work:

Wage or salary desired:

Are you willing to relocate:

Yes No

Are you willing to travel:

Yes No

Are you willing to work extra hours, weekends and evenings:

Yes No

Are you at least 18 years of age?

Yes No

Education

	Name & Location	Number of Years Completed	Did You Graduate? (Yes or No)	Grade	Major Field of Study	Minor Field of Study	Scholastic Standing GPA
High School
College
University
Business, Technical, Other

Scholastic honors, scholarships, assistantships, awards, publications, etc.

Company Name:

Company Address:

Dates Employed (From-To)

Month/Year

Your Job Title

Reason for leaving:

Supervisor's Name:

Supervisor's Title:

Telephone:

May we contact:

Yes No

Provide a brief description of your work and responsibilities:

Company Name:

Company Address:

Dates employed (From-To)

Month/Year

Your Job Title:

Reason for leaving:

Supervisor's Name:

Supervisor's Title

Telephone:

May we contact:

Yes No

Provide a brief description of your work and responsibilities:

Company Name:

Company Address:

Dates Employed (From-To)

Month/Year

Your Job Title:

Reason for leaving:

Supervisor's Name:

Supervisor's Title:

Telephone:

May we contact:

Yes No

Provide a brief description of your work and responsibilities:

Company Name:

Company Address:

Dates Employed (From-To)

Month/Year

Your Job Title:

Reason for leaving:

Supervisor's Name:

Supervisor's Title:

Telephone:

May we contact:

Yes No

Provide a brief description of your work and responsibilities:

Computer Software Applications:

Professional Registrations:

Other Skills:

Adding Skills Calculator Dictation Equipment Data Entry Shorthand

Typing WPM:

Please list any other applicable skills:

High School and College Activities (include if applicable, office or position held)

Professional & Technical Organizations (include if applicable, office or position held)

Civic and Recreational Activities:

Name:

Telephone Number:

Address:

Name:

Telephone Number:

Address:

Name:

Telephone Number:

Address:

I certify that, to the best of my knowledge, the information given in this application and any attachments are true and correct. I understand that any incorrect, incomplete, false or misleading statement, answer or information will subject my application to disqualification from further consideration, or if employed, may subject me to termination of employment. I hereby agree that the Company may investigate my qualifications with previous employers, personal references and other background security. If employed, I agree to execute a confidentiality/assignment of invention agreement, in consideration of such employment. I understand my employment with the Company is terminable at-will and would not be for any fixed period of time, and I may resign at any time for any reason or the Company may terminate my employment at any time for any reason with or without notice, and that this application is not and is not intended to be a contract for continued employment. I understand that according to law all individuals who are hired must as a condition of employment produce certain documentation to verify their legal authorization to work in the U.S. As a consequence, I understand that offer of employment, (and continued employment) would be contingent on my ability to produce the required documentation within the time period required by law. I have read and understand all of the provisions of this statement and acknowledgement. By signing this application, I hold the Company harmless from any result of the reference check. I hereby authorize and release from liability all former employers, educational institutions, law enforcement agencies or other governmental agencies to provide or release information regarding my employment, education, credit history*, driver’s license and motor vehicle records that may be in their possession, to the Company or its agents. I further understand that an offer of employment (and continued employment) is conditioned upon several criteria, including my satisfactorily passing certain laboratory test (including test for substance abuse) which may be required by the Company.

(*Please see the disclosure form provided by HR.)

By typing my name I have read and understand the applicant statement and acknowledgement: *

Date

Month Day Year

bluespace Employment Application

Job Interest

Personal

Provide ONLY the information requested in this employment application form. Failure to do so will result in disqualification of your application.

Employment History- List Most Recent Employer First

Work Experience 2:

Work Experience 3

Work Experience 4

Special Skills

Activities

References:

Reference #2

Reference #3

Applicant Statement and Acknowledgement