Please provide the following information as completely and accurately as possible:

PERSONAL INFORMATION
First Name
Last Name
Middle Initial
Social Security Number (Will be required upon employment)
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
County
Work Phone
Home Phone
FAX
E-mail
Web Site URL
Date of Birth
Sex			Male Female
POSITION
What Position are you applying for?			Auditor/Accounting Associate Sales
How did you hear about this position?			Newspaper Ad: (Please specify paper): Direct Contact Referred By:
Are you applying for a full or part time position?			Full Time  Part Time
When can you start if hired?			Immediately One Month On or later than:
Salary Requirements ($)
WORK HISTORY AND QUALIFICATIONS
Are you currently employed			YesNo
If yes, may we contact your employer?			YesNo
Have you previously applied to LTC Consulting			YesNo
Are you willing to work overtime?			YesNo
Do you have a valid driver's license?			YesNo
Have you even been convicted of a felony? Note: this question does not apply to convictions which have been expunged or sealed. (A conviction record will not necessarily be a bar to employment.)			YesNo
If so, please describe fully the criminal conviction(s), listing the nature of the offense(s) and your rehabilitation since the conviction(s).
EDUCATIONAL BACKGROUND
Highest level of education			High School (Did not graduate)High School GraduateCollege (Did not graduate)College GraduateTrade, Business or Graduate School
Name of School(s)
Major Area of Study (if applicable)
Special Skills (if applicable)
WORK EXPERIENCE
Please list your employers for the last two years, starting with your present or last place of employment (up to a maximum of four employers). Also include any verifiable work performed on a volunteer basis, internship or military service. Please list your current employer first.
Mo./Yr	Name, Address, & Phone No. of Employer	Salary (/Yr.)	Position	Name of Supervisor	Reason for Leaving
From: To:
From: To:
From: To:
From: To:
REFERENCES
Please give the names of three additional work-related references we may call. Please do not list relatives. Individuals with no prior work experience may list school- or volunteer-related references.
Name and Position		Company Name		Phone Number
1.
2.
3.
APPLICANT'S STATEMENT
I agree to conform to the rules and regulations of the company, and I understand that the company has complete discretion to modify such rules and regulations at any time, except that it will not modify its policy of employment at will. The above information is complete and true to the best of my knowledge. I understand that any misrepresentation or omission on my part of the facts in this application may result in immediate dismissal. I hereby authorize you to conduct any investigation necessary concerning any part of my background related to the position I am seeking. I release all parties from any liability in connection with the provision and use of such information. If you come in for interview, you will be asked to sign a printed copy of this form.
I agree:			Yes No
Type your name to confirm:

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