Olathe
15665 S. Mahaffie St.
Olathe, KS 66062

claims@alternativeclaims.com


TAKE OUR
CUSTOMER SURVEY
PERSONAL INFORMATION

First Name

Middle Name

Last Name

Street Address:

City, State Zip:

Phone:

Email:


Are you eligible to work in the United States?
YES     NO

If you are under age 18, do you have an employment/age certificates?
YES     NO

Have you been convicted of or pleaded no contest to a felony within the last five years?
YES     NO

If yes, please explain



POSITION & AVAILABILITY

Position Applied For


Days/Hours Available
Monday      Tuesday      Wednesday      Thursday      Friday
Saturday      Sunday

Hours Available
From      To

What date are you available to start work?



EDUCATION

Name & Address of School, Degree/Diploma, Graduation Date


Skills & Qualifications: Licenses, Skills, Training, Awards



EMPLOYMENT HISTORY

Present or Last Position

Employer


Address


Supervisor


Phone


Email


Position Title


From      To

Responsibilities


Salary


Reason For Leaving




Previous Position

Employer


Address


Supervisor


Phone


Email


Position Title


From      To

Responsibilities


Salary


Reason For Leaving



May we contact your present employer?
YES     NO


REFERENCES

Name/Title/Address/Phone





I certify that information contained in this application is true and complete.

I understand that false information may be grounds for not hiring me or for immediate termination of
employment at any point in the future if I am hired. I authorize the verification of any or all
information listed above.

Date