Date: _______________

Consultant’s
Initials:______
Keith Bagg Information Technology Search Inc.
Welcome to Keith Bagg IT Search (also known as The Bagg Group). Please help us by reviewing and filling out this
candidate information form completely.

NAME
Last First Preferred
Promm Jeremy Jeremy

CONTACT INFORMATION
Home phone # Cell phone # Work phone # Email address
416-887-4638 jpromm@hotmail.com

ADDRESS
Street Address City, Province Postal Code
Toronto, Ontario M3B 1C4
2 Montesson St
Major Intersection Date Available for Work Notice Required

OTHER LANGUAGE ABILITIES:

1._________________________________  Speak  Read  Write
2._________________________________  Speak  Read  Write
3._________________________________  Speak  Read  Write
COMPENSATION
… if on a Contract basis … if on a Salary basis Location
Current or Most Recent Current or Most Recent Relocate? (Circle one of below)
45,000
Yes / No
Desired Desired Desired Geographical Preference (if yes to
above)
50,000 Toronto
Minimum Minimum
42,000

Desired Perks (bonus, expenses, etc.) Access to transportation?

N/A
Yes / No

CONTRACTOR INFORMATION
Company name if independent contractor:

Current place of employment:

GST#
What motivates you to stay/join a company? What are your top 3 technical skills?
1. 1.

2. 2.

3. 3.
WORK HISTORY
Current/Most Recent Next Most Recent Position Next Most Recent Position
Position
Company Name Loblaw companines Ltd Kroll Computer systems Grand & Toy

Dates Employed From: Jun.09 To: From: Sept.04 From: Spet. 01

Jun.10 To: Mar.09 To:Aug. 04
Permanent or Contract Permanent Permanent
Contract?

Position/Title Support Analysis Pharmacy Support & Support Retail Buyer & Customer Service
Analysis Rep

Person Reported to Kris Ramdath Team Lead Dave Wear V.P. of Ops
& Title:

Earnings 45,000 per year 37,000 per year

Type of Business Store Support Pharmacy Softwear Retail

Reason for Leaving Moved Support to Department Re-structured Moved to Toronto

Montreal

I, ____Jeremy Promm_____________________________, permit The Bagg Group to conduct

reference checks at the appropriate time, with former clients or employers given as
references in this application, on my resume, and during any interview conducted, and in no
way hold The Bagg Group liable upon the release of this information or its findings to The
Bagg Group’s client. I acknowledge that information provided by me to my Consultant and
on my resume is accurate and true. I acknowledge that I accept The Bagg Group’s Privacy
Policy as available on their website and at their office. I further acknowledge that The Bagg
Group will not send out my resume without first informing me. I permit The Bagg Group to
conduct a search for Contract or Full Time Positions on my behalf. I acknowledge I am not
an employee of The Bagg Group, and although I am completing this candidate information
form, I have not commenced employment or have not engaged in a business to business
agreement. I further acknowledge and agree that The Bagg Group has not yet assigned me
to a client and that The Bagg Group will contact me when such an attempt is about to be
made and then, on my first day of work, my business to business contract or employment
with The Bagg Group will commence. I further consent to the retention of my personal
information by The Bagg Group as long as I am using the company’s placement services. In
the event that I wish to withdraw my consent to the use, disclosure and retention of my
personal information, I understand that it is my responsibility to inform The Bagg Group in
writing, at which time I will be informed by The Bagg Group whether and how such
withdrawal will affect the services being provided to me.

Signature: _______________________________ Date:

_____10/20/10__________________________

FOR INTERNAL USE ONLY

Add to hotlist? Yes__________ No____________ Hotlist Category: ____________________________
ATTRIBUTES EVALUATI NOTES
ON
Technical Skills /5
Presentation Skills /5
Communication Skills /5
Adaptive, Flexible, Copes with Change /5
Team Player /5
Management Skills /5
Team Leadership Skills /5
Committed to Ongoing Personal /5
Development
 FOR INTERNAL USE ONLY
Client / Job interviewing for:

Skill sets needed:

Interview notes:

Rev. Oct 2009