Online Application

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This information will not be the only basis for hiring decisions. You are not required to furnish any information that is prohibited by federal, state or local law.

Application Form

First Name

Middle Name

Last Name

Home address

City

State

Zip code

Area code + telephone no.

Business address

City

State

Zip code

Area code + telephone no.

Phone/Mobile

Date

Position applied for

Earnings expected $

I. BUSINESS EXPERIENCE: (Please start with your present or most recent position.) REMINDER: DO NOT COMBINE JOBS— FILL OUT A COMPLETE SECTION OF THIS FORM FOR EVERY JOB WHERE JOB TITLE CHANGED.

A.

Firm

Address

Kind of business

Starting date (mo/yr)

Final (mo/yr)

Title

Staff: Number of direct reports:

Total Staff:

Salary (Starting)

Base $

Bonus $

Other $

Salary (Final)

Base $

Bonus $

Other $

Name of immediate supervisor

Title

What is your best guess as to how this supervisor would rate your overall performance?

Excellent

Very Good

Good

Fair

Poor

Impossible to Provide

If rating is impossible to provide, please explain

What do (did) you like most about your job?

What do (did) you least enjoy?

If you are leaving or have left the company, please indicate your motivation to leave.

100% Mine

Mutual

100% Company’s (I was fired)

Options don’t fit circumstance

If options don’t fit circumstance, please explain

Reason(s) for leaving

REMINDER: DO NOT COMBINE JOBS—FILL OUT A COMPLETE SECTION OF THIS FORM FOR EVERY JOB WHERE JOB TITLE CHANGED.

B.

Firm

Address

City

State

Zip code

Area code + telephone no.

Kind of business

Starting date (mo/yr)

Final (mo/yr)

Title

Staff: Number of direct reports:

Total Staff:

Salary (Starting)

Base $

Bonus $

Other $

Salary (Final)

Base $

Bonus $

Other $

Name of immediate supervisor

Title

What is your best guess as to how this supervisor would rate your overall performance?

Excellent

Very Good

Good

Fair

Poor

Impossible to Provide

If rating is impossible to provide, please explain

What do (did) you like most about your job?

What do (did) you least enjoy?

If you are leaving or have left the company, please indicate your motivation to leave.

100% Mine

Mutual

100% Company’s (I was fired)

Options don’t fit circumstance

If options don’t fit circumstance, please explain

Reason(s) for leaving

REMINDER: DO NOT COMBINE JOBS—FILL OUT A COMPLETE SECTION OF THIS FORM FOR EVERY JOB WHERE JOB TITLE CHANGED.

C.

Firm

Address

City

State

Zip code

Area code + telephone no.

Kind of business

Starting date (mo/yr)

Final (mo/yr)

Title

Staff: Number of direct reports:

Total Staff:

Salary (Starting)

Base $

Bonus $

Other $

Salary (Final)

Base $

Bonus $

Other $

What is your best guess as to how this supervisor would rate your overall performance?

Excellent

Very Good

Good

Fair

Poor

Impossible to Provide

If rating is impossible to provide, please explain

What do (did) you like most about your job?

What do (did) you least enjoy?

If you are leaving or have left the company, please indicate your motivation to leave.

100% Mine

Mutual

100% Company’s (I was fired)

Options don’t fit circumstance

Company

City, State

Performance Rating

Date Began(mo/yr)

Name of supervisor

If left the company after this job, Motivation for Leaving

Your title

Date Left(mo/yr)

Initial Compensation

Final Compensation

Type of work

Your title

Date Left(mo/yr)

Initial Compensation

Final Compensation

Type of work

Indicate by letter

Letter(s) of Employer(s)

any of the above employers you do not wish contacted

II. MILITARY EXPERIENCE:

If in service, indicate branch

Date (mo/yr) entered

Date (mo/yr) discharged

Nature of duties

Highest rank or grade

Terminal rank or grade

III. EDUCATION:

High School

College/Graduate School

(Input X below number for highest grade completed)

High School

Name of High School

Location

Approximate number in graduating class

Rank from the top

Final grade point average

(A = )

Extracurricular activities

Offices, honors, and awards

Part-time and summer work

College/Graduate School

Name and location

Dates From

Dates To

Degree

Major

Grade Point Average

Total Credit Hours

Extracurricular activities, honors and awards

Name and location

Dates From

Dates To

Degree

Major

Grade Point Average

Total Credit Hours

Extracurricular activities, honors and awards

Name and location

Dates From

Dates To

Degree

Major

Grade Point Average

Total Credit Hours

Extracurricular activities, honors and awards

What undergraduate courses did you like most? Why?

What undergraduate courses did you like least? Why?

How was your education financed?

Part-time and summer work

Other courses, seminars, or studies

IV. ACTIVITIES:

Membership in professional or job-relevant organizations (You may exclude groups that indicate race, color, religion, national origin, disability, or other protected status.)

Publications, patents, inventions, professional licenses, or additional special honors or awards

What qualifications, abilities, and strong points will help you succeed in this job?

What are your weak points and areas for improvement?

V. CAREER NEEDS:

Willing to relocate?

Yes

If no, explain

Amount of overnight travel acceptable

What are your career objectives?

VI. RATINGS BY BOSSES:

If you were to be asked to arrange calls with bosses you’ve had in the past 8 years, what is your best guess as to how they would rate

you (the rating scale is: 5 = Excellent, 4 = Very Good, 3 = Good, 2 = Fair, 1 = Poor) on the following:

Judgment/Decision Making

Resourcefulness/Initiative

Drive/Energy

Team Player

Likability

Leadership

VII. OTHER:

Do you have the legal right to work for any employer in the United States?

Yes

Would you be willing to arrange reference calls with supervisors you’ve had in the past decade, as a last step before a final job offer?

Yes

I certify that the answers given in this Career History Form are true, accurate, and complete to the best of my knowledge. I authorize an investigation into all statements I have made on this Form as may be necessary for reaching an employment decision. I understand that I may be asked to arrange reference calls with managers I’ve worked for.

In the event I am employed, I understand that any false or misleading information I knowingly provided in my Career History Form or interview(s) may result in discharge and/or legal action. I understand that if employed, I am required to abide by all rules and regulations of the employer and any special agreements reached between the employer and me.

Signature

Sign Here

Date

Please return this form to the company requesting its completion, not to Smart & Associates, Inc.

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