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First Name*
Last Name*
Middle Name
Suffix
Nickname
Address*
Apt/Box/Suite
City*
State*
Zip*
Cell Phone
Home Phone
Emergency Contact Name*
Emergency Contact Number*
Have you ever used another name?*

Include any detail necessary to successfully complete a check on your background, work or school history.
Date Available For Work*
Minimum Compensation Required minimum PER HOUR for temporary hourly positions (ex 7.25)
Maximum Salary Required salary for salaried permanent positions (exp 21,000) per year

Education & Certifications
Can you, after a conditional job offer is made submit valid documentation for legal right to work in the United States? *

If hired would you have adequate transportation to and from?*


High School
School Name
City
State
Degree/Certification
Status

College/University
Name of College
City
State
Highest Degree Received
Status

Please list any specific skills or certifications that you have?
  






Job Types
Select the job titles below that describe your current position and experience, then select the industry you have experience. Press the CTRL key to select multiple Titles and Industries.
Position Title / Experience
Industries

Employment History
Please enter the 3 most recent jobs which you have held.
Job 1
Company Name
Job Title
Department
Address
Supervisor's Number
Supervisor's Name
Supervisor's Title
Start Date
End Date
Starting Salary
Present/Ending Salary
Reason For Leaving
Job Description
Job 2
Company Name
Job Title
Department
Address
Supervisor's Number
Supervisor's Name
Supervisor's Title
Start Date
End Date
Starting Salary
Present/Ending Salary
Reason For Leaving
Job Description
Job 3
Job Title
Department
Address
Supervisor's Number
Supervisor's Name
Supervisor's Title
Start Date
End Date
Starting Salary
Present/Ending Salary
Reason For Leaving
Job Description

References
Please list at least two references, these references will be verified so complete information is required.
Reference Name*
Reference Title
Reference Phone Number*
Reference Email Address
Reference Type/Relationship*

Second Reference
Reference Name*
Reference Title
Reference Phone Number*
Reference email address
Reference Type/Relationship:*
Have you been terminated or asked to resign from any employer?

Please explain any details of the instance.
Please explain any gaps of more than 2 weeks in employment history.
Criminal Background Check

Applicants — please note:

  • Before answering this question please review the information below if you live in one of the states listed here.
  • A conviction wil not necessarily disqualify you from the position.


    • California Applicants Only — You may omit:

  • Marijuana-related misdemeanor convictions occurring more than two years ago.
  • Offenses committed before your 18th birthday and tried as a juvenile.
  • Any misdemeanor conviction which has been judicially dismissed.
  • Any conviction for which a pre-trial diversion program has been successfully completed.
  • Any conviction for which the records have been judicially ordered sealed, expunged, or statutorily eradicated.
  • Note: Conviction of Driving under the Influence is a misdemeanor and must be reported if you were 18 years of age or older at the time of the incident.

    • Connecticut Applicants Only — Applicant is not required to disclose the existence of any arrest, criminal charge or conviction, which has been erased pursuant Conn. Gen. State §§46b-146, 54-760, 54-142a. The arrest or criminal charge or conviction which has been erased are records pertaining to a finding of delinquency or that a child was a member of a family with service needs, an adjudication as a youthful offender, a criminal charge that has been dismissed or annulled, a criminal charge of which the person has been found not guilty or a conviction for which the person received an absolute pardon. In addition, any person whose criminal records have been erased pursuant to the above, is deemed to have never been arrested within the meaning of the general statues with respect to the proceedings so erased and may so swear under oath.


    Illinois Applicants Only — Applicant is not obligated to disclose expunged juvenile records of convictions or arrest; or sealed or expunged records of conviction or arrest.


    Massachusetts Applicants Only — An applicant for employment with a sealed record on file with the Commissioner of Probation may answer “no” with respect to any inquiry relative to prior arrests, criminal court appearances or convictions. In addition, any applicant for employment may answer “no” with respect to any inquiry relative to prior arrests, court appearances and adjudications in all cases of delinquency or as a child in need of services which did not result in a complaint transferred to superior court for criminal prosecution.


    New Hampshire Applicants Only — Please respond to this question only:
    Have you ever been arrested for or convicted of a crime that has not been annulled by a court?

    Washington Applicants Only — Please note that applicants do not have to report arrests or convictions which occurred more than 10 years ago.

    Hawaii Applicants Only — Do not answer this question at this time. You will only have to answer this question if you receive a conditional offer of employment. At that time you will be asked whether you have been convicted of a crime within the past ten (10) years.
    Have you ever been convicted of a felony or misdemeanor or are currently awaiting trial for any criminal offenses?*

    Conviction Explanation If you respond "yes" please provide the following information below. Give date, charge, plea, place, court and action taken for each offense. False statements or misrepresentation will disqualify you from consideration. If you have any questions concerning this section of this form please contact the Human Resource Department at Gazelle HR.
    Have you ever been in the military?

    If so, were you ever convicted by general court martial?


    Certification of Application

    I certify that all information on this application are true and complete. I understand that any false statement, omission or misrepresentation are discovered my application will be rejected, or if I am employed I will be terminated at any time. I hereby authorize any person, educational institution I have listed on my references on my employment application to disclose in good faith any information they may have regarding my qualifications and fitness for employment. I will hold Gazelle HR and any Affiliated company (GHR Holdings, Inc., Payroll Management Inc, Payroll Management Inc. a Delaware Corporation), any former employers, educational institutions or references free from liability for providing this information or providing any other documents, records or information incident to the employment process. In consideration for my employment I agree to conform to the company's rules and regulation and I understand that my compensation and employment can be terminated with or without cause, with or without notice at my or the company's option. I understand that the terms and conditions of my employment can be changed with or without cause or with or without notice by Gazelle HR or any affiliated companies, (PMI Employee Leasing, Payroll Management Inc, Payroll Management Inc a Delaware Corporation.) By signing this certification either electronically, of physically I agree that I have read and fully understands the conditions of my employment and seek employment under my free will and under my own judgement. I understand that no Gazelle HR or affiliated companies can enter into an employment contract or any agreement of employment for any specific period or time or contrary to the foregoing, except in writing signed by the President of Gazelle HR, PMI Employee Leasing, Payroll Management Inc, Payroll Management Inc a Delaware Corporation.
    Employee Signature*
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    Password*
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