Employment Application

Date of Application: ________________ __________________________________________________

Last Name _______________________ First Name ____________________________Middle Initial ___

Address__________________________________ City

State________________ Zip ____________ Email ___________________________________________

Home Phone ____________________________ Cell Phone ____________________________________

Employment History

An accurate and complete full-time and part-time employment record must be provided. Start with present or most
recent employer

MAY WE CONTACT YOUR PRESENT EMPLOYER: ❑ Yes ❑ No

Most Recent Employer __________________________________________________________________

Address ______________________________________________________________Phone ____________________

Employed From Mo/Yr ___________________________________ to Mo/Yr _________________________________

Final Salary $_________________________________ ❑ Hourly ❑ Weekly ❑ Monthly ❑ Annually

Bonus/Commission $ ___________________________Name & Title of Supervisor ____________________________

Previous Employer _____________________________________________________________________

Address ______________________________________________________________Phone ____________________

Employed From Mo/Yr ___________________________________ to Mo/Yr _________________________________

Final Salary $_________________________________ ❑ Hourly ❑ Weekly ❑ Monthly ❑ Annually

Bonus/Commission $ ___________________________Name & Title of Supervisor ____________________________

Previous Employer _____________________________________________________________________

Address ______________________________________________________________Phone ____________________

Employed From Mo/Yr ___________________________________ to Mo/Yr _________________________________

Final Salary $_________________________________ ❑ Hourly ❑ Weekly ❑ Monthly ❑ Annually

Bonus/Commission $ ___________________________Name & Title of Supervisor ____________________________

2500 Green Road, Suite 400 ● Ann Arbor, MI 48105 ● Phone: 734.205-2600 ● Fax: 734.352.6303
Last Revision date: May 1, 2009

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Previous Employer _____________________________________________________________________

Address ______________________________________________________________Phone ____________________

Employed From Mo/Yr ___________________________________ to Mo/Yr _________________________________

Final Salary $_________________________________ ❑ Hourly ❑ Weekly ❑ Monthly ❑ Annually

Bonus/Commission $ ___________________________Name & Title of Supervisor ____________________________

References

Please provide three references, including at least one current or former manager, Be sure to list work and cell phone
numbers with area codes, as well as email addresses, where possible.

Reference #1
Name _________________________________________________________________________________________

Current Position_________________________________________________________________________________

Company ______________________________________________________________________________________

Relationship ____________________________________________________________________________________

Work Phone _____________________________________ Cell __________________________________________

Email Address __________________________________________________________________________________

Reference #2
Name _________________________________________________________________________________________

Current Position_________________________________________________________________________________

Company ______________________________________________________________________________________

Relationship ____________________________________________________________________________________

Work Phone _____________________________________ Cell __________________________________________

Email Address __________________________________________________________________________________

Reference #3
Name _________________________________________________________________________________________

Current Position_________________________________________________________________________________

Company ______________________________________________________________________________________

Relationship ____________________________________________________________________________________

Work Phone _____________________________________ Cell __________________________________________

Email Address __________________________________________________________________________________

2500 Green Road, Suite 400 ● Ann Arbor, MI 48105 ● Phone: 734.205-2600 ● Fax: 734.352.6303
Last Revision date: May 1, 2009

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Education and Training

Name and Location of School Course of No. of Did You Last Year Degree
Study Years Graduate Attended
Completed

High School

College

Additional College or Other

List any other education, training, special skills, or certificates/licenses that you possess which are relevant to the
position for which you have applied:

General Information

Position Desired: Pay Range Desired:

Are you eligible to work in the United States? Have you previously applied for work with
ForeSee Results?
Yes ❑ No ❑
Yes ❑ No ❑ If yes, when:

When are you available to begin work? Have you reached your 18th Birthday?

Yes ❑ No ❑

If your job requires, are you willing to travel? Do you require ForeSee Results to sponsor you for a
working visa?
If yes, what % of travel time is reasonable? Yes ❑ No ❑

Are you consistently able, with or without accommodation, to perform safely and efficiently all of the
essential duties and requirements of the position(s) for which you would like to be considered?
❑ Yes ❑ No
(If no, please explain) _________________ _________________________________________________________

____________________________________ _________________________________________________________

____________________________________ _________________________________________________________

2500 Green Road, Suite 400 ● Ann Arbor, MI 48105 ● Phone: 734.205-2600 ● Fax: 734.352.6303
Last Revision date: May 1, 2009

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Have you ever been convicted of a crime (including any misdemeanors) which has not been annulled,
expunged, or sealed by a court? (Please note: an affirmative response will not automatically disqualify
you from being considered for employment) ❑ Yes ❑ No

If yes, please describe* in full detail: ______ _________________________________________________________

____________________________________ _________________________________________________________

____________________________________ _________________________________________________________

____________________________________ _________________________________________________________

*Any information provided in response to this inquiry will be considered only to the extent that it is job-related.

How did you learn about our organization and/or this position?

❑ Employee Referral/Name: ❑ Recruiter

❑ Publication/News/Other Media ❑ Job Fair

❑ Agency ❑ Online Service

❑ ForeSee Web Page ❑ Other

Authorization & Signature

I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and
complete to the best of my knowledge. I understand falsified or omitted information may disqualify me from further
consideration for employment with ForeSee Results; and also separation from employment with ForeSee Results if
falsified information is discovered after employment commences.

I further understand that my employment would be “at will” for an indefinite period, that I would have the right to
terminate my employment with ForeSee Results at any time for any reason, and that ForeSee Results has the right to
terminate my employment with or without cause, and with or without prior notice, at any time. I also understand that
any offer of employment extended to me will contingent upon my signing ForeSee Results Employee Agreement, my
being free from any contractual obligations that would prevent me from performing my job duties, and any other
conditions stated in my offer letter.

I hereby authorize persons, schools, institutions and employers named in my application and /or resume, as well as
any other source deemed appropriate by ForeSee Results, to provide additional relevant information that may be
required to arrive at an employment decision or as requested during my employment by a client. I further authorize
ForeSee Results to conduct or request third party investigations into the information provided in my resume and/or
application, including but not limited to a complete background and credit check.

Signature (Required) ____________________________________________________Date ______________________

2500 Green Road, Suite 400 ● Ann Arbor, MI 48105 ● Phone: 734.205-2600 ● Fax: 734.352.6303
Last Revision date: May 1, 2009

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