APPLICATION FOR EMPLOYMENT FOR USE IN SPECIFIC JURISDICTIONS (WITH CRIMINAL HISTORY, WITH SALARY HISTORY) 10007 # © 2019 Insperity. All rights reserved. Page 1 of 5 (Rev. 05-21-19) Note: This application is not for use in California, Connecticut, Delaware, Hawaii, Kansas City (MO), Massachusetts, New Mexico, New York City (NY), Albany and Westchester Counties (NY), Oregon, Philadelphia (PA), Vermont, Washington, and Washington (DC). Name of Insperity Client Company (if applicable and known) How did you hear about the position for which you are applying? EQUAL OPPORTUNITY EMPLOYER. It is our policy to abide by all federal, state and local laws prohibiting employment discrimination based on a person’s race, color, religious creed, sex, national origin, ancestry, citizenship status, pregnancy, childbirth, physical disability, mental and/or intellectual disability, age, military status, veteran status (including protected veterans), marital status, registered domestic partner or civil union status, familial status, gender (including sex stereotyping and gender identity or expression), medical condition (including, but not limited to, cancer related or HIV/AIDS related), genetic information, sexual orientation, or any other protected status. — PLEASE TYPE OR PRINT IN INK — Today’s Date First Name MI Last Name Last 4 Digits of Social Security No. Current Mailing Address How long at current address? City County State ZIP Code Daytime Telephone Home Telephone Email Address Position for which you are applying Date available for work What is your minimum salary requirement? Check the following options you would consider. Full-Time Part-Time Temporary If part-time, specify hours and days available. Are you subject to any type of agreement with a current or former employer or entity that would restrict your ability to work at Insperity or the client company to which you have applied (e.g., non-compete, non-solicitation)? Yes No If Yes, explain and provide a copy of such agreement. EDUCATION & TRAINING SCHOOL NAME CITY AND STATE DEGREE/DIPLOMA MAJOR COURSE OF STUDY DEGREE RECEIVED? High School Yes No GED Yes No Colleges* Yes No Graduate School Yes No Trade School Yes No Indicate School and Last Name(s) Used at Time of Graduation * Only list colleges or universities accredited by the Department of Education (DOE). The DOE maintains a database of accredited institutions at http://ope.ed.gov/accreditation. It is your responsibility to verify accreditation. List coursework undertaken or degree/diploma received from an unaccredited college, as well as any other education, training, special skills or certificates/licenses that you possess related to the job. Professional License/Certification # Professional License/Certification Type Issuing Agency State Issued Expiration Date Professional License/Certification # Professional License/Certification Type Issuing Agency State Issued Expiration Date