PH: (860) 678-1300 FX: (860) 678-1919
AN EQUAL OPPORTUNITY EMPLOYER
ON-LINE SYSTEMS
APPLICATION FOR STAFF POSITION
Please attach your resume. Application MUST be completed even if resume is attached. PLEASE PRINT CLEARLY.
PERSONAL INFORMATION
Last Name First Name Middle Name Social Security NumberStreet Address Apt.#
City State Zip Code Driver’s License Number State Issued
Home Phone Work Phone Cellular/Pager # E-Mail
Prior Address City State Zip Code
I understand that upon employment, proof of legal right to work in the United States and completion of I-9 form will be required.
-Have you ever been convicted of or pleaded guilty to any crime of dishonesty or breach of trust, either felony or misdemeanor, including any misdemeanor or felony that has not been expunged, annulled, or sealed by court order? Yes No ( If Yes, on an attached sheet, list: offense, date and place of conviction, sentence, and date of release from custody and/or from probation/parole. A felony conviction does not automatically disqualify you from employment.)
- Have you ever participated in a pretrial diversion or like program for a crime involving dishonesty or breach of trust? Yes No
-Are you the subject of any order prohibiting you from working for a financial institution? Yes No
WORK EXPERIENCE ( Please list past 10 years, use separate sheet if necessary)
Current/Last Employer (name and address) / Dates Employed: From: To:Contact Name/email/telephone number
Previous Employer (name and address) / Dates Employed: From: To:
Contact Name/email/telephone number
Previous Employer (name and address) / Dates Employed: From: To:
Contact Name/email/telephone number
Previous Employer (name and address) / Dates Employed: From: To:
Contact Name/email/telephone number
CERTIFICATION OF APPLICANT
I hereby certify that all statements made in this application are true and I authorize investigation and verification of all matters contained in this application without giving me prior notice of such disclosure. I understand that any misstatement or omission of material fact will cause forfeiture on my part of all rights of employment with On-Line Systems, Inc.
If I am employed, I agree to abide by the rules and regulations of On-Line Systems, Inc. I understand that my employment is at-will. This means that I do not have a contract of employment for any particular duration or limiting the grounds for my termination in any way.
I understand that On-Line Systems will use Info Cubic, LLC. to conduct a background check. For the purpose of completing a background check only, please provide others name used (if applicable).
Other Names Used______
Signature ______Date ______