Online Application

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Current Date:

Name*

Address*

Primary Phone Number*

Position Desired

Start Date Available

Are you legally eligible to work in the U.S.? (Proof of identity and eligibility are required if selected for hire)

Yes

Are you over the age of 18? (If no, you may be required to provide authorization to work.)

Yes

Do you require any reasonable accommodations to perform the duties of the position you are applying for?

Yes - If yes, please describe below.

Description of reasonable accommodations required

How did you hear about this employment opportunity?

Please list the days and hours you are available to work:

Have you been employed by Diverse Options, Inc. in the past?

Yes - If yes, provide position title, dates of employment and previous name(s):

Position title, dates of employment and previous name(s):

Education History -

List your high school and college education below.

School/Institution #1 = Name (Include City and State)

School/Institution #1 = Level of Education

School/Institution #1 = Did you Graduate?

Yes

School/Institution #1 = Name of Diploma/Degree Completed

School/Institution #2 = Name (Include City and State)

School/Institution #2 = Level of Education

School/Institution #2 = Did you Graduate?

Yes

School/Institution #2 = Name of Diploma/Degree Completed

School/Institution #3 = Name (Include City and State)

School/Institution #3 = level of Education

School/Institution #3 = Did you Graduate?

Yes

School/Institution #3 = Name of Diploma/Degree Completed

Please list any special skills, experience, licenses/certifications and/or training you have that would enhance your ability to perform the position you are applying for.

Has a state licensing authority ever revoked, suspended or placed conditions upon a professional/occupational license you either currently hold or have held in the past?

If yes, please explain below.

Licensing Explanation

Employment History - Previous Employer #1

Employer Name (Include City and State): Employer #1

Start Date / End Date: Employer #1

Job Title: Employer #1

Immediate Supervisor Name/Title: Employer #1

Please summarize your job responsibilities: Employer #1

Reason for Leaving: Employer #1

Previous Employer #2

Date Started / Date Ended: Employer #2

Employer Name (Include City and State) : Employer #2

Job Title: Employer #2

Immediate Supervisor Name/Title: Employer #2

Please summarize your job responsibilities: Employer #2

Reason for Leaving: Employer #2

Employer #3

Date Started / Date Ended: Employer #3

Employer Name (Include City and State): Employer #3

Job Title: Employer #3

Immediate Supervisor Name/Title: Employer #3

Please summarize your job responsibilities: Employer #3

Reason For Leaving: Employer #3

Employer #4

Date Started / Date Ended: Employer #4

Employer Name (Include City and State): Employer #4

Job Title: Employer #4

Immediate Supervisor Name/Title: Employer #4

Please summarize your job responsibilities: Employer #4

Reason For Leaving: Employer #4

PROFESSIONAL EMPLOYMENT REFERENCES

List the names and contact information for three individuals you have worked with who can attest to your qualifications for the position you are applying for.

Name of Reference #1:

Reference #1 Phone Number:

Reference #1 Business Name / Reference Job Title:

Relationship (i.e. supervisor, co-worker, customer, etc..) #1:

Name of Reference #2:

Reference #2 Phone Number:

Reference #2 Business Name / Reference Job Title:

Relationship (i.e. supervisor, co-worker, customer, etc..) #2:

Name of Reference #3:

Reference #3 Phone Number:

Reference #3 Business Name / Reference Job Title:

Relationship (i.e. supervisor, co-worker, customer, etc..) #3:

AUTHORIZATION AND ACKNOWLEDGMENT

Please read carefully before signing.

I certify that the information I have provided in this application is true and complete to the best of my knowledge, and I have not knowingly withheld any information requested. I understand that any falsified statements or omission of information on this application may disqualify me from further consideration for employment or, if hired, may be grounds for dismissal.

I authorize Diverse Options, Inc. to verify my references, record of employment, education record, and any other information I have provided. Unless otherwise noted, I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release Diverse Options, Inc., my former employers and all other persons and entities, from any and all claims, demands or liabilities arising out of or in any way related to such inquiry or disclosure.

I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date and payment of my wages and salary, be terminated at any time without prior notice and without cause.

Name - Digital Signature*

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In accordance with state and federal laws, Diverse Options, Inc. considers all qualified applicants for employment without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, sexual orientation, genetic information or any other protected characteristic under applicable law.

Employment Application

Education History -

List your high school and college education below.

Employment History - Previous Employer #1

Previous Employer #2

Employer #3

Employer #4

PROFESSIONAL EMPLOYMENT REFERENCES

Positions Available

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