Personal Information:

Contractor Name______________________________________ SS# ____________________Present Address ___________________________________City___________________Zip_____ Phone( _ _ _ ) _ _ _-_ _ _ _

Are you 18 years or older ? YES NO D.O.B.___________________________
Employment Desired:
Position___________________ Date you can start _______________Full time_____ Part time_____
Are you employed or providing services on contract now? YES_____ NO_____
May we inquire of your present employer/Clients? YES____ NO___
Provides Services to/Supervisor’s Name___________________________Cell ( _ _ _ ) _ _ _ - _ _ _ _
Education:
High School ______________________________ # of years_______ Did you Graduate?___________
College__________________________________ # of years _______ Did you Graduate?___________
Trade School, etc.__________________________ # of years _____ Did you Graduate?___________
Personal References: Please list 3 non-relatives whom you have known for at
least 2 years.
NAME PHONE RELATIONSHIP YEARS KNOWN
In case of Emergency , address of nearest relative: Name/Address___________________________________ Cell ( _ _ _ ) _ _ _ - _ _ _ _

Previous / Current Contract  Employment:
Please list the past (3) (Most recent first)
Company name Address____________________________________________________________ Phone_________________________________________

Date Start______________________________Date End___________________ Last Position______________________
Pay rate/Start___________Pay rate/End__________Reason for Leaving______________________________________

Supervisor’s Name________________________________ Cell. ( _ _ _ ) _ _ _ - _ _ _ _
Duties Required to Perform__________________________________________________________

_________________________________

________________________________________________________________

Company name Address_______________________________________Phone_____________

____________________

Date Start__________________ Date End___________________ Last Position______________________
Pay rate/Start_________Pay rate/End_________________Reason for Leaving_________________________________

Supervisor’s Name___________________________________Phone /Cell ( _ _ _ ) _ _ _ - _ _ _ _ 

Duties Required to Perform__________________________________________________________

_____________________________________________________________________________________________ 

Company name Address_______________________________________________Phone_____________ 

Date Start__________________ Date End___________________ Last Position______________________ Pay rate/Start_________Pay rate/End_________________Reason for Leaving_________________________________

Supervisor’s Name___________________________________Cell ( _ _ _ ) _ _ _ - _ _ _ _

What days or evenings are you available to work?(below) 

________________________________________

What hours are you available to work? (enter below)
Are there any activities that would prevent you from working certain days and or hours? (enter below) Monday Tuesday Wednesday Thursday Friday Sunday

AM
You will be Asked to work Sunday
PM
You will be Asked to work Sunday
List any criminal record/ If applicable ________________________________________________

Include DMV Report
DUI Convictions?___________________________

Why do you feel you would be a a good service provider for WELLNESS2U? _________________________________________________

What do you consider to be your outstanding qualities?

____________________________________________________

What do you consider to be your worst qualities?

__________________________________________________________

What kind of circumstances makes you nervous or tense?

__________________________________________________

Will it affect your work behavior? ________________________________________________________________ _______
Would you take a DRUG TEST ?_________ Since handling cash, would you
take a Polygraph (Lie detector Test?)_______

Have you ever been convicted of a felony or misdemeanor? YES____ NO___ (if YES, explain)__________________________________________________________ List your favorite hobbies/interest: 1.___________________2.____________________ 3.____________________ 

DMV driving record negative Points? YES NO

List any special skills or Specialized Services:____________________________ _____________________________________________________________________________________

Applicant represents that all information given on this application is true and
correct. Applicant hereby authorizes verification of all references and facts, including but not limited to current and previous employers, and personal references. Applicant hereby authorizes owner/agent/manager to obtain, Company, Personal Credit Reports, background reports. Applicant understands we contract service providers.

Applicant hereby waives any claim providing or obtaining said verification or additional information and releases from liability any person facts contained in this application are true and complete to the best of my knowledge and understand that, application shall be grounds for dismissal. if employed, falsified statements of this Applicant understands that incomplete or incorrect information provided in the application may cause a delay in processing which may result in denial of employment.
I certify that the

_____________________________ ________________________________

Applicant Signature

*INCLUDE SALARY HISTORY e-mail completed app to: sales@AcimaB2B.com