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Independent Profile Status  

Date:                                                          Referred by:                                                        ID#  

Entry Opportunities:  Independent Online Rep  /   Independent Online Manager Rep 

Desired Opportunity:                                                         ID#:                                                                                                                                                                         Your ID# will be selected by the company.  Your ID# will not be changed without proper authorization.

Name:                                                                                     Date of Birth:                                                Age:      


City:                                                                       State:                                            Zip code

Mailing Address:

City:                                                                       State:                                            Zip code

Telephone:                                    Cell:                             Personal Email Address:                                                                                    

Personal Email Address:

What is your favorite color?

In case of an emergency, Notify:                                                            Telephone Number : 

Are you a Citizen of the USA or are you approved to work in the United States?

What documents can you provide as proof of citizenship or legal status?


What is the highest school grade completed?       Award: Diploma / Degree / GED / Certification:

Are you a student?       Name of school attending:                                                                                          State:

List Skills/Qualifications you posses for this opportunity:

Employment History 

Present Firm Name:                                                                                               State:                                  Zip:           

Years employed:            Position:                                                                              Salary:

Reason(s) for leaving: 

Previous Firm Name:                                                                                             State:                                   Zip:          

Years employed:            Position:                                                                             Salary:

Reason(s) for leaving:

AT WILL OPPORTUNITY: U.S. labor law for contractual relationships in which an employee can be dismissed by an employer for any reason (that is, without having to establish "just cause" for termination), and without warning.

Have you ever been convicted of a felony, or a misdemeanor involving any violent act, use or possession of a weapon or stealing, act of dishonesty for which the record has notbeen sealed or expunged? If yes, please briefly describe the nature of the crime(s), the date and place of conviction and the legal disposition of the case. This company will not deny employment to any applicant solely because the person has been convicted of a crime. The company however, may consider the nature, date and circumstances of the offense as well as whether the offense is relevant to the duties of the position applied for. 


Additional Information

Future Goals:

Will this be a main source of earnings? Yes /No  Are there any illnesses that could inhibit performance? Yes /No



Receipt Date: __________________________________Receipt Time: _______________________________   



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