(Please Print Clearly)

Personal Data
Name	Date
Permanent Address
Phone Number	Social Security No.
(Required at time of hire)
Job Interest
Position Applied For	Salary Desired
Are you employed now?	Yes No	May we contact your present employer?	Yes No
Indicate Availability to Work:	Full time	Part time	Days	Evenings
Available to Start:	Referral Source:
Have you ever applied to IMS before?	Yes	No
Have you ever been employed by us before?	Yes	No
Are you legally permitted to work in this country?	Yes	No
Are you above the minimum working age for RI?	Yes	No
Have you ever been convicted of a felony?	Yes	No
If yes, please explain:

Please indicate availability to work:

Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
AM PM	AM PM	AM PM	AM PM	AM PM	AM PM	AM PM

Education
Type	Name and Location	Courses Taken	Graduated
Grammar School	Yes No Enrolled
High School	Yes No Enrolled
College (University)	Yes No Enrolled
Business, Trade, Technical	Yes No Enrolled
Job related Skills or Special Studies	Yes No Enrolled
Other	Yes No Enrolled

Exclude organizations, the name or character of which indicates the race, gender, color or national origin of its members.

Employment History (List previous employers beginning with most recent)
Company Name	Business Type
Address
Supervisor	Supervisor Title
Position	Full Time Part Time Temporary
Employment Dates (mm/yy)	From:	To:	Ending Salary:
Reason for Leaving:	May we Contact?	Yes No
Company Name	Business Type
Address
Supervisor	Supervisor Title
Position	Full Time Part Time Temporary
Employment Dates (mm/yy)	From:	To:	Ending Salary:
Reason for Leaving:	May we Contact?	Yes No
Company Name	Business Type
Address
Supervisor	Supervisor Title
Position	Full Time Part Time Temporary
Employment Dates (mm/yy)	From:	To:	Ending Salary:
Reason for Leaving:	May we Contact?	Yes No

Company Name	Business Type
Address
Supervisor	Supervisor Title
Position	Full Time Part Time Temporary
Employment Dates (mm/yy)	From:	To:	Ending Salary:
Reason for Leaving:	May we Contact?	Yes No

Professional References (Please list three professional reference below)
Name	Company and Title	Business Telephone	Home Telephone

AUTHORIZATION & UNDERSTANDINGS:

I understand that if I am hired by IMS, I will be required to attest to my identity and employment eligibility, and to present documents confirming my identity and employment eligibility. I further understand that I cannot be hired if I cannot comply with these requirements.

I certify that the facts contained in this application (and accompanying resume, if any) are true and complete to the best of my knowledge. I understand that any false statement, omission, or misrepresentation on this application is sufficient cause for refusal to hire, or dismissal if I have been employed, no matter when discovered by IMS.

I understand that any employment is conditioned on a background check. I authorize IMS to thoroughly investigate all statements contained in my application or resume, and I authorize my former employers and references to disclose information regarding my former employment, character, and general reputation to IMS, without giving me prior notice of such disclosure. In addition, I release IMS, any former employers, and all references listed above from any and all claims, demands, or liabilities arising out of or related to such investigation or disclosure.

I understand and agree that nothing contained in this application, or conveyed during any interview, is intended to create an employment contract. I further understand and agree that if I am hired, my employment will be “at will” and without fixed term, and may be terminated at any time, with or without cause and without prior notice, at the option of either myself or IMS. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon the Company unless made in writing.

I understand that filling out this form does not indicate that there is a position open and does not obligate IMS to hire. If hired, I agree to abide by all IMS company rules, policies, and procedures. IMS retains the right to revise its policies or procedures, in whole or in part, at any time.

Applicant Signature:	Date: