PERSONAL INFORMATION Complete all applicable information. Fields marked in bold are required Name (Full - Last, First, MI)     Position(s) applied for              Are you willing to work:  Full Time   Part Time Temporary Are there any hours in the day or weekdays you cannot or will not work? Street Address Physical address, no P.O. Box address City, State, Zip Daytime Phone   Bus. Phone           Fill out if you want us to contact you via e-mail   Have you been previously employed with PSI?  No  Yes When? Are you willing to work overtime as required? Yes No When could you start employment? How did you learn about this opening? Search Engine Newspaper Referral Other Are you over 18 years old?  Yes   No Wage or salary desired:  / Hour Month Year Are you authorized to work in the US on an unrestricted basis? Yes No

EMPLOYMENT HISTORY List below last three (3) employers, starting with the most recent one. Present or Last Position Name of Company From Mo/Yr To Mo/Yr Street Address   City, State, Zip   Duties:  Reason for Leaving:   Starting Salary/Wages:  / Hour Month Year Final Salary/Wages:  / Hour Month Year Bonus Commission May we contact your supervisor? Yes No Name/Title/Department/Phone Number of Supervisor   Previous Position Name of Company From Mo/Yr To Mo/Yr Street Address City, State, Zip Duties:  Reason for Leaving:   Starting Salary/Wages:  / Hour Month Year Final Salary/Wages:  / Hour Month Year Bonus Commission May we contact your supervisor? Yes No Name/Title/Department/Phone Number of Supervisor   Next Previous Position Name of Company From Mo/Yr To Mo/Yr Street Address City, State, Zip Duties:  Reason for Leaving:   Starting Salary/Wages:  / Hour Month Year Final Salary/Wages:  / Hour Month Year Bonus Commission May we contact your supervisor? Yes No Name/Title/Department/Phone Number of Supervisor

EDUCATION INFORMATION
High School/GED	Address, City, St, Zip	Diploma  Yes No
College	Address, City, St, Zip	Degree/Major/GPA
College	Address, City, St, Zip	Degree/Major/GPA
Graduate School	Address, City, St, Zip	Degree/Major/GPA
Other	Address, City, St, Zip	Degree/Major/GPA

GENERAL INFORMATION In addition to your work history, what other experiences, skills, or qualifications would especially fit you for work with our company? Have you been told the essential functions of the job or have you been shown a copy of the job description listing the essential functions of the job?   Yes No Can you perform these essential functions with or without reasonable accommodations?       Yes No   Have you ever been convicted of a felony? (conviction will not necessarily disqualify an applicant for employment) Yes No If yes, please describe the conditions: If applying for a secretarial position, please list your typing skills (wpm) If applying for a secretarial position, what business equipment can you operate? (list computers, copiers, etc.) In what computer software programs are you proficient? (Name the package(s)

Please read the following statements carefully!

• In consideration of my employment I agree to conform to the policies and procedures of the company. I understand that in accepting this application, the company is in no way obligated to provide me with employment, and that I am not obligated to accept employment if offered. Furthermore, if employed, I understand that I am employed at will and that my employment and compensation can be terminated with or without cause, and with or without notice at any time. All employment is continued on that basis. I understand that no supervisor, manager, or executive of the Company, other than the President in a signed writing has any authority to alter the foregoing.
   
• I certify that the facts contained in this application are true and complete to the best of my knowledge. I understand that any falsified statements on this application or omission of fact on either this application or during the pre-employment process will result in my application being rejected, or, if I am hired, in my employment being terminated. I authorize the Company to make an investigation of the facts set forth in this application and release the Company from any liability.
   
• I also understand that any offer of employment is conditioned on the completion of pre-employment tests and documentation. I will, upon request, sign all necessary consent forms.
  
   
• I am aware that submitting this form to PSI via the Internet constitutes a legal and binding signature.