Contractor Application

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

CONTRACTOR APPLICATION NET(net) and its’ subsidiary entities offers equal 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 *

Type of contract desired: *

Date Available: *

Date

Number of hours per week:

Identify days and times available:

Are you available for overtime or additional days?

Yes No

Monthly Fees desired (USD) - Base? *

Monthly Fees desired (USD) - Commission? *

Have you ever been convicted of, pled guilty 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 / contracted engagement or quit to avoid discipline? *

No

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

Yes No

Have you ever applied to or worked at NET(net) before? *

Yes No

How did you hear about the opportunity at NET(net) ?

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 (USD) - Base *

Annual Commission (USD) *

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 (USD) - Base

Annual Commission (USD)

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 (USD) - Base

Annual Commission (USD)

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 *

E-mail *

Name *

Type of Reference *

Company / Organization / Relationship

Phone *

E-mail *

Name

Type of Reference

Company / Organization / Relationship

Phone

E-mail

Name

Type of Reference

Company / Organization / Relationship

Phone

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 PROFICIENCY

	Native	Full Proficiency	Limited Proficiency	No Proficiency
English
Dutch
French
German
Italian
Portuguese
Russian
Spanish

Additional Language(s) & Proficiency

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

Attach Resume and/or References

Select File

CERTIFICATION 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 engagement. Any offer is conditioned upon satisfactorily passing any physical or mental examination required by NET(net). I hereby give NET(net) permission to contact any and all former employers, associates, and schools they find necessary in determining my eligibility. 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) reserves the right to terminate the contract 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 contracted work for a specified period of time and that no person may modify this condition 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 application and information. Signature of Applicant *

Today's Date *

Date

Position Applying For: