Last Name: First: Middle: Maiden:

Present Address:

City: State: Zip Code:

How Long at Current Address?: SSN:   

Telephone: Are you under age 18?: No Yes ,

 if "Yes", can you provide proof of your eligibility to work?: Yes No

Are you currently authorized to work in the United States?: Yes No Proof of eligibility will be required if hired.

Position Applied for: ClientServiceRep PackoutPerson TaxSpecialist Wage Desired:   

Days/hours available to work:

No Pref: Mon: Tues: Wed: Thur: Fri: Sat: Sun:

How many hours can you work weekly?:

Employment Desired: Full-Time Part-Time Full or Part Time When can you start?:  

Have you ever been convicted of a crime which is substantially related to the functions or qualifications of the job for which you are applying?: No Yes

If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed and type(s) of rehabilitation.