EMPLOYMENT APPLICATION

Population Services International (PSI) is an equal opportunity employer and will consider all qualified applicants
for employment without regard to race, color, sex, national origin, religion, age, disability, or any other factor
prohibited by law.

This application will be given every consideration, but its receipt does not imply that the applicant will be employed.
Each question should be answered in a complete and accurate manner as no action can be taken on this application
until all questions have been answered.

LAST NAME FIRST NAME

ADDRESS

MOBILE TELEPHONE BUSINESS TELEPHONE E-MAIL ADDRESS

POSITION DESIRED SALARY REQUIREMENT DATE AVAILABLE

MARKETING MANAGER $

Would you be willing and able to report to work on time every work day YES NO
on a regular and consistent basis?

If no, please explain:

May we contact your present employer? NOT EMPLOYED YES NO

Have you ever been fired or asked to resign from a job? YES NO

If yes, please explain:

If you are employed, please state how much notice you are required to give to your present employer:

Use the spaced below to describe why you are interested in working for PSI and to list those skills and abilities
which you feel particularly qualify you for a position with us.
PROFESSIONAL REFERENCES
*Providing this information means you grant PSI permission to contact the persons listed below or listed on a separate page you
have provided us. PSI will not be held liable for any information found while checking references. In the space below, please list
three professional references.

One supervisor (past or current) must be included. Please include name, occupation, location (city/state), contact information
(including email address/ phone), and relationship to you.

1.
2.
3.

EDUCATION
NAME & CITY/STATE COURSE OF YRS ATTENDED YRS/CREDITS GPA DIPLOMA/
OF SCHOOL STUDY FROM/TO COMPLETED DEGREE
AWARDED

EMPLOYMENT HISTORY

Starting with most recent position, and going back in time.

NAME OF COMPLETE ADDRESS TELEPHONE NUMBER
COMPANY/ORGANIZATION

TITLE SUPERVISOR’S NAME

DATE OF EMPLOYMENT STARTING SALARY* ENDING (PRESENT) SALARY*

FROM TO $ $
REASON FOR LEAVING/SEEKING NEW EMPLOYMENT

NAME OF COMPLETE ADDRESS TELEPHONE NUMBER

COMPANY/ORGANIZATION

TITLE SUPERVISOR’S NAME

DATE OF EMPLOYMENT STARTING SALARY* ENDING SALARY*

FROM TO $ $
REASON FOR LEAVING

*Please provide base salary, exclusive of any benefits, allowances or bonuses.

AFFIDAVIT
I certify that my answers to the foregoing questions are true and correct without any consequential omissions of any kind
whatsoever. I understand that any false information provided will disqualify me from employment with PSI. I understand that if
I am employed, any false, misleading or otherwise incorrect statements made on this application form or during any interviews
may be grounds for my immediate discharge. I hereby authorize PSI to contact any company or individual it deems appropriate
to investigate my employment history, character and qualifications and I give my full and complete consent to their revealing any
and all information they wish for this investigation. In addition, I hereby waive my right to bring any cause of action against
these individuals for defamation, invasion of privacy or any other reason because of these statements. I understand that only the
PSI President or his designee is authorized to enter into any written employment contract with me.

Signature: Date: