Collection Agency - Chasemax, Inc.

Employment Application

An Equal Opportunity
We are an Equal Opportunity employer, and we do not, and will not, discriminate on the basis of race, religion, national origin, sex, age, handicap, marital status, or status as a disabled veteran. Information provided on this application will not be used for any discriminatory purpose.

Contact Information

Last Name
First Name
Middle Name
Social Security Number
Date of Birth
Street Address
City
State
ZIP
Home Telephone
Alternate Telephone
Type of Work Desired

Employment Record

Most recent or Present Company
Type of Business
Supervisor's Name
Streeet Address
City
State
ZIP
Phone
Dates of Employment	to
Brief Description of Job Duties

** Company
Type of Business
Supervisor's Name
Streeet Address
City
State
ZIP
Phone
Dates of Employment	to
Brief Description of Job Duties

** Company
Type of Business
Supervisor's Name
Streeet Address
City
State
ZIP
Phone
Dates of Employment	to
Brief Description of Job Duties
*** Can you have a reliable form of transportation?	yes I can No

Educational History

High School
Location (City,State)
Dates Attended
Graduated
College/Vocational School Name
Dates Attended
Graduated
Any other training

Professional/Work References

Name:	Title:	Phone:
Name:	Title:	Phone:
Name:	Title:	Phone:

I hereby certify that the answers and other information on this application are true and correct and that I understand any misrepresentation or omission of the facts on my part will be justification for separation from the company's service, if employed. I understand that my employment may be contingent upon receipt of an alien registration number, verification of birth, and any other pertinent information bearing upon my employment, and that my continued employment depends upon the will of the company or myself.

Type "YES" to agree with the above terms and conditions