Personal

Name

First name

Last name

Social Security Number / Driver's Liscense Number

Present Address

Street

City

State

Zipcode

Home Phone

Mobile Phone

Permanent Address, if different from present address

Street

City

State

Zipcode

If hired can you provide proof that you are legally able to work in the United States?

Yes No

How were you referred to us?

Advertisement Employee Employment Agency Walk-in Other

Have you ever been convicted of a criminal offense (felony or misdemeanor)?

Yes No

Do you have any relatives or friends employed by Premiere Business Solutions, LLC? Yes No

Employment

Position Desired

Salary Desired

What days and hours are you available to work?

Are you available for overtime?

Yes No

Are you over 18 years of age?

Yes No

Are you able to perform the essential functions of the job for which you are applying? Yes No

(Note: We comply with the Americans with Disabilities Act and consider reasonable accommodation measures that may be necessary for eligible applicants to perform essential functions)

Skills

Many of our [customers/clients/patients] do not speak English. Do you speak, write or understand any foreign language?

Yes No

Are you able to operate a personal computer?

Yes No

List other office machines you can operate: Specific skills or training: