EMPLOYMENT APPLICATION*
  Personal Information


Name (Last Name First):
Email Address:
Address:
City:
State:
ZipCode:
Permanent Address:
Telephone:
Referred By:
  Desired Position


Title of Position:
Desired Salary/Wage: $
Date you can start:
Are you currently employed?: Yes No
May we contact your Employer:
(If you answered Yes to above)		 Yes No
Have you ever applied to this company before?: Yes No
Month/Year you previously applied:
  Educational Background


HIGH SCHOOL
Name and Location:
Date of Attendance: From ( Year ): To ( Year ):
Graduated?:
(If Applicable)		 Yes No
Subjects studied?:
(If Applicable)
COLLEGE
Name and Location:
Date of Attendance: From ( Year ): To ( Year ):
Graduated?:
(If Applicable)		 Yes No
Subjects studied?:
(If Applicable)
BUSINESS/TRADE/CORRESPONDENCE
Name and Location:
Date of Attendance: From ( Year ): To ( Year ):
Graduated?:
(If Applicable)		 Yes No
Subjects studied?:
(If Applicable)
  Special Interests


Military/Naval Service:
Special Skills/Training:
Special Study/Hobbies:
  Employment History (Beginning with most current)


Employer #1
Employer Name and Location:
Telephone:
Employment Dates: From ( Year ): To ( Year ):
Position Held:
Ending Salary $
Reason for leaving
Employer #2
Employer Name and Location:
Telephone:
Employment Dates: From ( Year ): To ( Year ):
Position Held:
Ending Salary $
Reason for leaving
Employer #3
Employer Name and Location:
Telephone:
Employment Dates: From ( Year ): To ( Year ):
Position Held:
Ending Salary $
Reason for leaving
  References (Please provide three references whom you have known at least 1 year)


Reference #1
Reference Name and Location:
Telephone:
Type of Business:
Number of years known:
Reference #2
Reference Name and Location:
Telephone:
Type of Business:
Number of years known:
Reference #3
Reference Name and Location:
Telephone:
Type of Business:
Number of years known:
In submitting this form you agree to following statements:

"I certify that the information I have provided in this application is true and complete to the best of my knowledge and I understand that one or more falsified statements within this application is ground for dismissal.

I authorize investigation of all statements contained herein and, the references and employers listed within to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and I release the company from all liability for any damage that may result from use of said Information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

This waiver does not permit the release or use of disability-related or medically-related information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws."

 

  
 *DISCLAIMER-Applicants are Independent Contractors for Merchant Alliance, LLC.  
 
     
   
   
             
             

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are the property of their respective owners. The First Data Independent Sales Agent Program is operated by Cardservice International, Inc. Cardservice International, d/b/a First Data Independent Sales is a registered ISO/MSP for Wells Fargo Bank, NA, Walnut Creek, CA. American Express requires separate approval. FDIS Pacific Northwest is an Independent Agent for Cardservice International.