Employment Application

General Information

Date:

Name:

Social Security Number:

Email:

Phone:

Street Address:

City:

State:

Zip/Country Code:

Country:

Are you 18 years old or older? Yes No

Are you eligible to work in the United States? Yes No

Please list any preferred position you are seeking:

If you were referred by someone to Ashcom, please indicate:

Education

Work Experience

Physical Record

Do you have any physical limitations that might preclude you from performing any work for which you are being considered:

Yes No

If "yes", please describe:

Do you have you any defects in any of the following? Please select all that apply:

Hearing
Vision
Speech

Person to notify in emergency:

Relationship:

Phone:

References

Please provide three references (unrelated) whom you have known for at least 1 year:

Office Skills

Please list the office machines your are familiar with:

Typing speed (WPM):

Please select all following skills that you are capable of:

Dictation
Transcription
Multi-Line Phone Management

Please list any other training, experience, skills or credentials:

Final Authorization

PLEASE READ CAREFULLY BEFORE ACCEPTING:

I certify that the facts contained in this Application are true and complete to the best of my knowledge. I understand that, if employed, falsified statements on this Application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references listed above.

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

By checking this box, you acknowledge the above statements.