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APPLICATION FOR EMPLOYMENT FOR USE IN SPECIFIC JURISDICTIONS (WITH CRIMINAL HISTORY, WITH SALARY HISTORY) 10007 # © 2019 Insperity. All rights reserved. Page 1 of 5 (Rev. 05-21-19) Note: This application is not for use in California, Connecticut, Delaware, Hawaii, Kansas City (MO), Massachusetts, New Mexico, New York City (NY), Albany and Westchester Counties (NY), Oregon, Philadelphia (PA), Vermont, Washington, and Washington (DC). Name of Insperity Client Company (if applicable and known) How did you hear about the position for which you are applying? EQUAL OPPORTUNITY EMPLOYER. It is our policy to abide by all federal, state and local laws prohibiting employment discrimination based on a person’s race, color, religious creed, sex, national origin, ancestry, citizenship status, pregnancy, childbirth, physical disability, mental and/or intellectual disability, age, military status, veteran status (including protected veterans), marital status, registered domestic partner or civil union status, familial status, gender (including sex stereotyping and gender identity or expression), medical condition (including, but not limited to, cancer related or HIV/AIDS related), genetic information, sexual orientation, or any other protected status. — PLEASE TYPE OR PRINT IN INK — Today’s Date First Name MI Last Name Last 4 Digits of Social Security No. Current Mailing Address How long at current address? City County State ZIP Code Daytime Telephone Home Telephone Email Address Position for which you are applying Date available for work What is your minimum salary requirement? Check the following options you would consider. Full-Time Part-Time Temporary If part-time, specify hours and days available. Are you subject to any type of agreement with a current or former employer or entity that would restrict your ability to work at Insperity or the client company to which you have applied (e.g., non-compete, non-solicitation)? Yes No If Yes, explain and provide a copy of such agreement. EDUCATION & TRAINING SCHOOL NAME CITY AND STATE DEGREE/DIPLOMA MAJOR COURSE OF STUDY DEGREE RECEIVED? High School Yes No GED Yes No Colleges* Yes No Graduate School Yes No Trade School Yes No Indicate School and Last Name(s) Used at Time of Graduation * Only list colleges or universities accredited by the Department of Education (DOE). The DOE maintains a database of accredited institutions at http://ope.ed.gov/accreditation. It is your responsibility to verify accreditation. List coursework undertaken or degree/diploma received from an unaccredited college, as well as any other education, training, special skills or certificates/licenses that you possess related to the job. Professional License/Certification # Professional License/Certification Type Issuing Agency State Issued Expiration Date Professional License/Certification # Professional License/Certification Type Issuing Agency State Issued Expiration Date
 
APPLICATION FOR EMPLOYMENT FOR USE IN SPECIFIC JURISDICTIONS (WITH CRIMINAL HISTORY, WITH SALARY HISTORY) 10007 © 2019 Insperity. All rights reserved. Page 2 of 5 (Rev. 05-21-19) GENERAL INFORMATION APPLICANT NAME EDUCATION & TRAINING (CONTINUED) List any machines, equipment or software programs on which you are qualified and experienced in operating. List any languages that you speak fluently. List any languages that you read/write fluently. If you are applying for a position which involves driving a motor vehicle in the course and scope of the employment duties, please indicate whether you have a valid driver’s license in this state. Yes No If you are applying for a government contractor position, please specify whether you have a security clearance and what level the security clearance is: Can you, after employment, submit verification of your legal right to work in the United States? Yes No Are you 16 years old or over? No Yes Age 16 17 18 or over Within the past 7 years, have you been employed, or are you currently employed by Insperity/Administaff or an Insperity/Administaff Client? Yes No If Yes, give dates: From: (month/year) To: (month/year) Do not identify your marital status in your response. Do you have any relatives currently working at Insperity/Administaff? Yes No Do you have any relatives serving on the Board of Directors for Insperity/Administaff? Yes No Do you have any relatives currently working at the client company to which you are applying? Yes No If Yes to any of the above questions, please list the relatives: EMPLOYMENT HISTORY (List all work experience beginning with the present or most recent job. Insperity will contact all previous employers to verify your employment. Please list your current or most recent employer first and indicate whether you are currently employed in the boxes provided. Insperity will not contact your current employer without permission. You may also include any volunteer and/or military work. Use back of application, if necessary.) CURRENT / MOST RECENT JOB Name of Employer Type of Business Address City State ZIP Code Title Type of Employment Part-Time Full-Time Supervisor Name Supervisor Phone Number Human Resource/Payroll Phone Number May We Contact? Yes No Employed From (month/year) Employed To (month/year) Last Salary $ Brief Description of Duties Reason for Leaving PREVIOUS EMPLOYMENT Name of Employer Type of Business Address City State ZIP Code Title Type of Employment Part-Time Full-Time Supervisor Name Supervisor Phone Number Human Resource/Payroll Phone Number May We Contact? Yes No Employed From (month/year) Employed To (month/year) Last Salary $ Brief Description of Duties Reason for Leaving
 
APPLICATION FOR EMPLOYMENT FOR USE IN SPECIFIC JURISDICTIONS (WITH CRIMINAL HISTORY, WITH SALARY HISTORY) 10007 © 2019 Insperity. All rights reserved. Page 3 of 5 (Rev. 05-21-19) EMPLOYMENT HISTORY (CONTINUED) APPLICANT NAME PREVIOUS EMPLOYMENT Name of Employer Type of Business Address City State ZIP Code Title Type of Employment Part-Time Full-Time Supervisor Name Supervisor Phone Number Human Resource/Payroll Phone Number May We Contact? Yes No Employed From (month/year) Employed To (month/year) Last Salary $ Brief Description of Duties Reason for Leaving PREVIOUS EMPLOYMENT Name of Employer Type of Business Address City State ZIP Code Title Type of Employment Part-Time Full-Time Supervisor Name Supervisor Phone Number Human Resource/Payroll Phone Number May We Contact? Yes No Employed From (month/year) Employed To (month/year) Last Salary $ Brief Description of Duties Reason for Leaving PREVIOUS EMPLOYMENT Name of Employer Type of Business Address City State ZIP Code Title Type of Employment Part-Time Full-Time Supervisor Name Supervisor Phone Number Human Resource/Payroll Phone Number May We Contact? Yes No Employed From (month/year) Employed To (month/year) Last Salary $ Brief Description of Duties Reason for Leaving PREVIOUS EMPLOYMENT Name of Employer Type of Business Address City State ZIP Code Title Type of Employment Part-Time Full-Time Supervisor Name Supervisor Phone Number Human Resource/Payroll Phone Number May We Contact? Yes No Employed From (month/year) Employed To (month/year) Last Salary $ Brief Description of Duties Reason for Leaving
 
APPLICATION FOR EMPLOYMENT FOR USE IN SPECIFIC JURISDICTIONS (WITH CRIMINAL HISTORY, WITH SALARY HISTORY) 10007 © 2019 Insperity. All rights reserved. Page 4 of 5 (Rev. 05-21-19) ADDITIONAL INFORMATION APPLICANT NAME CRIMINAL RECORD INFORMATION (Instructions for answering the next two questions below): A. All Applicants. Do not include convictions that were sealed, eradicated, dismissed, erased, annulled by a court, expunged, pardoned or deferred AND withdrawn. B. Colorado Applicants. Exclude information involving any record of civil or military disobedience unless such matters resulted in a plea of guilty or a conviction by a court of competent jurisdiction. C. Connecticut, Hawaii, Illinois, Massachusetts, Minnesota, New Jersey, Oregon, Rhode Island, Vermont and Washington Applicants. Do not answer the following two questions. D. Michigan Applicants. Regarding pending charges, limit your response to felony offenses. E. New York Applicants. Exclude any adjudications as a youthful offender. F. Utah Applicants. Regarding convictions, limit your response to felony convictions. Do not respond to the second question (regarding pending charges). G. Cities of Baltimore (MD), Buffalo (NY), Columbia (MO), Kansas City (MO), Rochester (NY), Seattle (WA) and Austin (TX) Applicants. Applicants residing in these cities or applying for a position physically located in these cities do not answer the following two questions. H. Counties of Montgomery County (MD) and Prince George’s County (MD) Applicants. Applicants residing in these counties or applying for a position physically located in these counties do not answer the following two questions. 1. Convictions/Pleas. In the past seven (7) years, have you ever been convicted of, or pled guilty or no contest to, any felony offense other than any applicable exceptions listed above? Yes No 2. Pending Matters. Have you been arrested for any matters for which you are now out on bail or on your own recognizance pending trial? Yes No CRIMINAL RECORDS: If you answered Yes to either of the above two questions, please provide the date(s), what county and describe that criminal record so the individual circumstances can be considered. Criminal convictions or pending matters will not automatically disqualify an applicant from employment. An individualized assessment will be conducted in accordance with local, state and federal law before any employment decision is made. BUSINESS REFERENCES (List three individuals, in addition to listed employment references, known to you for at least three years.) Name Occupation/Association Telephone Email Address 1. 2. 3. Please include any other information you think would be helpful to us in considering you for employment, such as additional work experience, articles/books published, activities, honors received, etc. You may omit all information that would indicate age, sex, sexual orientation, race, religion, color, national origin, disability or any other protected class.
 
APPLICATION FOR EMPLOYMENT FOR USE IN SPECIFIC JURISDICTIONS (WITH CRIMINAL HISTORY, WITH SALARY HISTORY) 10007 © 2019 Insperity. All rights reserved. Page 5 of 5 (Rev. 05-21-19) ADDITIONAL INFORMATION APPLICANT NAME AGREEMENT (Please read the following statement carefully.) I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete to the best of my knowledge. I also agree that falsification or significant omission of information requested in this application or in the application process may disqualify me from further consideration for employment and may be considered justification for dismissal if discovered at a later date. I authorize all persons listed above (and on the accompanying resume, if any) to give Insperity any and all information concerning my previous employment and education and any pertinent information they may have, personal or otherwise, and release all parties, such persons and Insperity, from liability for any damage that may result from furnishing same to Insperity. If employed by Insperity and its client company, I agree to abide by the policies and procedures of Insperity and its client company, which include the Insperity Anti-Harassment Policy. I further understand that my employment can be terminated, with or without cause or notice, at any time, at the discretion of Insperity, the client company or myself. I further understand that no manager or representative of Insperity or its client company other than the president of Insperity has any authority to enter into any agreement, oral or written, on behalf of Insperity for a term of employment or to make any assurance or promise of continued employment. DRUG TESTING: I understand and agree that, subject to applicable law, I may be required to take a drug and alcohol screening test. I also understand that if I test positive for the presence of drugs or alcohol, I will be ineligible for employment with the company. FOR ARIZONA APPLICANTS: To the extent required by applicable law, a smoke free workplace is maintained. FOR CALIFORNIA APPLICANTS: I further understand that Insperity and/or its client company may obtain Public Records about me as part of an internal background investigation and that I may waive my right to receive a copy of such Public Records by checking this box: FOR MASSACHUSETTS APPLICANTS: Under Massachusetts Law, it is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties of civil liability. FOR RHODE ISLAND APPLICANTS: The company is subject to chapter 29-38 of title 28 of the General Laws of Rhode Island and is therefore covered by the state’s Workers’ Compensation law. SIGN AND DATE THE FORM Applicant’s Signature Date Signed (mm/dd/yyyy) Print Full Name Last 4 Digits of Social Security No. FOR MARYLAND APPLICANTS ONLY: Under Maryland law, an employer may not require or demand, as a condition of employment, prospective employment, or continued employment, that an individual submit to or take a lie detector or similar test. An employer who violates this law is guilty of a misdemeanor and subject to a fine not exceeding $100. Maryland Applicant’s Signature Date Signed (mm/dd/yyyy) Print Full Name Last 4 Digits of Social Security No.