Employment Application

217 E. 24th Street, Suite 10 Holland, MI 49423 (616) 546-3100 www.netnetweb.com

EMPLOYMENT APPLICATION NET(net), Inc. and its’ subsidiary entities offers equal employment opportunity to all, based upon individual merit and without regard to race, color, religion, national origin, sex, age, height, weight, marital status, disability or protected handicap.

First Name *

Middle Initial

Last Name *

E-mail

Phone *

Are you a U.S. Citizen, a lawful permanent resident or otherwise authorized for employment in the U.S.? *

Yes No

Type of employment desired: *

Date Available: *

Date

Number of hours per week:

Identify days and times available:

Are you available for overtime or additional days?

Yes No

Salary or hourly rate desired? *

Have you ever been convicted of, pled guilty to or no contest to any felony criminal offense, or are there any felony charges pending? *

No

Have you ever been suspended or discharged from employment or quit to avoid discipline? *

No

Are you qualified and capable of performing the essential functions of the job for which you are applying, either with or without accommodation? *

Yes No

Have you ever worked at NET(net), Inc or applied for employment before? *

Yes No

How did you hear about employment with NET(net), Inc.?

WORK EXPERIENCE OR VOLUNTEER EXPERIENCE List most recent or present position first. Do not skip any consecutive employments. Explain any periods of unemployment.

Employer *

Address or Website *

Employment Start *

Date

Employment End

Date

Position *

Annual Salary - Base *

Commission *

Reason for leaving?

Supervisor"s Name *

Business Phone No. *

OK to verify? *

Yes No

Employer

Address or Website

Employment Start

Date

Employment End

Date

Position

Annual Salary - Base

Commission

Reason for leaving?

Supervisor"s Name

Business Phone No.

OK to verify?

Yes No

Employer

Address or Website

Employment Start

Date

Employment End

Date

Position

Annual Salary - Base

Commission

Reason for leaving?

Supervisor"s Name

Business Phone No.

OK to verify?

Yes No

REFERENCES Please include at least one business and one personal reference.

Name *

Type of Reference *

Company / Organization / Relationship

Phone *

Fax

E-mail *

Name *

Type of Reference *

Company / Organization / Relationship

Phone *

Fax

E-mail *

Name

Type of Reference

Company / Organization / Relationship

Phone

Fax

E-mail

Name

Type of Reference

Company / Organization / Relationship

Phone

Fax

E-mail

EDUCATION AND TRAINING Include vocational schools and training programs as well as college and high school.

School / Program *

Completion Date

Date

Major(s)

Degree / Diploma /Certification Received

School / Program

Completion Date

Date

Major(s)

Degree / Diploma / Certification Received

School / Program

Completion Date

Date

Major(s)

Degree / Diploma / Certification Received

Language(s) & Fluency

Please list any specialized experience that you may bring to this position.

Attach Resume and/or References

Select File

CERTIFICATION Under Michigan law , you must request any necessary accommodation for a physical or mental handicap within 182 days after you know, or should know, of the need for accommodation. A form is available if you need to request accommodation. I certify that the information contained in this application is correct and complete to the best of my knowledge and belief. I realize that misrepresentation of facts called for on this application will be cause for rejection of this application or dismissal after employment. Any offer of employment is conditioned upon satisfactorily passing any physical or mental examination required by NET(net), Inc. I hereby give NET(net), Inc. permission to contact any and all former employers, associates, and schools they find necessary in determining my eligibility for employment. Also, I will not hold any of the above, nor individuals employed by the above, liable for furnishing or using the information requested and waive my right to receive written notice of any such information provided. NET(net), Inc. reserves the right to terminate employment at any time, with or without cause, at the sole discretion of the company. I also understand that no representative of the company has any authority to enter into any agreement for employment for any specified period of time and that no person may modify this condition of employment, except the President of the Company by an express written and signed contract.

By typing my name in the following box I certify the above statements to be true and correct, to the best of my knowledge, and that this information can be used for the purpose of processing my employment application and information. Signature of Applicant *

Today's Date *

Date

Position Applying For: