Qualtrax Compliance Software

TO APPLICANT

We appreciate your interest in our organization and assure you that we are interested in your qualifications. A clear understanding of your background and work history will aid us in placing you in the position that best meets your qualifications and may assist in possible future advancement. All information obtained in this application will be disseminated only according to the Privacy Protection Act of 1976. Law prohibits discrimination because of race, color, religion, national origin, sex, age or disability. If you believe that you have been discriminated against, you may notify the Department of Human Resources. Qualtrax is an Equal Opportunity Employer.

First Name * MI * Last Name * Phone * Email * Date (MM/DD/YYYY) * Position(s) Applying for Technical Support Specialist Address * City * State * Zip Code *

Have you been convicted of a crime in the past ten years, excluding traffic violations? *
Yes No

If yes, Please Explain

Are you legally authorized to work in the United States? *
Yes No

Will you now or in the future require sponsorship for employment visa status (i.e, H-1B status)? *
Yes No

ATTENTION: If you are applying for a position which requires driving vehicles, complete this section.

Do you have a valid drivers license? Yes No
State of Issue (Note: You may omit traffic violations for which you paid a fine of $50 or less)

EDUCATION INFORMATION

High School or GED * Degree * GPA Address City State Zip Code

College Degree GPA Address City State Zip Code

Graduate School Degree GPA Address City State Zip Code

Additional Skills / Certifications

EMPLOYMENT HISTORY

* Please provide relevant employment history (up to three positions).

Present or Last Position * Company * Start Date (MM/YYYY) * End Date (MM/YYYY) * Address City * State * Zip Code Duties * Reason for Leaving * Starting Annual Salary * Final Annual Salary * Bonus Commission Name of Supervisor * Title * Phone *
May we contact this employer? * YesNo

Contact Name Title Phone

Upload Resume (.pdf, .doc, or .docx only) *

Upload Cover Letter (.pdf, .doc, or .docx only)

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

• In consideration of my employment, I agree to conform to the policies and procedures of the company. I understand that in accepting this application, the company is in no way obligated to provide me with employment and that I am not obligated to accept employment offered. Furthermore, if employed, I understand that I am employed at will and that my employment and compensation can be terminated with or without cause, and with or without notice at any time.
• I certify that the facts contained in this application are true and complete to the best of my knowledge. I understand that any falsified statements on this application or omission of fact on either this application or during the pre-employment process will result in my application being rejected, or, if I am hired, in my employment being terminated.
• I also understand that any offer of employment is conditioned on the completion of pre-employment tests and documentation. I will, upon request, sign all necessary consent forms.

Full Name * Date (MM/DD/YYYY) *

I hereby authorize my employment history to be released to CCS. This information will remain confidential.

Full Name * Date (MM/DD/YYYY) *

Disclosure Release

This is to inform you that as part of our procedure for processing your employment application, the hiring company may use Information Resources, an independent outside agency. This agent may make an investigative report in which information is obtained through personal interviews with family members, business associates, financial sources, credit reporting agencies, friends, neighbors, educational institutions, driving records or abstract or motor vehicle reports from department of motor vehicles, courts, law enforcement agencies or other third parties with whom you are acquainted. This information will include inquiries as to your characteristics or mode of living, whichever is applicable.
By signing the document below you are releasing any and all persons, companies or others from any liability whatsoever for this purpose. You have the right to make a written request, within a reasonable period of time, for complete disclosure of additional information concerning the nature and scope of the investigation. Residents of California, Minnesota and Oklahoma only: If a credit report is part of the background screening process, you have the right to receive a copy of it. Please mark the appropriate box. Louisiana - American Driving Records will be the supplier of Louisiana driving Records.

I would like to receive a copy of my credit report: *YesNo

(applies only if the hiring company requests this service as part of your pre-employment screening)

Full Name * Date (MM/DD/YYYY) * All Other Names Used (Aliases, AKA's, Maiden) * Driver's License Number State Issued From Full Name as it Appears on Driver's License Expiration Date

Voluntary Information(For Identification Purposes Only):

* CCS (parent company of Qualtrax, Inc.) may contact you to obtain your Social Security Number before processing a background or credit check.

You have not entered all of the required fields. The missing fields have been highlighted. You must also enter a valid email address.