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Job Application Form
First Name
Middle Initial
Last Name
Maiden Name (if applicable)
Email
Phone Number
Street Address 1
Street Address 2
City
State
Zip Code
Which position are you interested in?
Please Select an Option...
Administration
Structured Cabling
Network Technician/Engineer
Sales
Marketing
Professional Development / Technology Trainer
Other
What are your salary expectations?
Please list a range
What date can you start?
(mm/dd/yyyy)
If you are employed, can you submit proof of citizenship?
Yes
No
Have you been convicted of a felony in the last ten years?
Yes
No
Are you a minor?
Yes
No
Do any of your relatives work at Synergetics?
Yes
No
Who referred you to this role?
Highest level of education completed
Please Select an Option...
High School or equivalent
Technical or occupational certificate
Associate degree
Some college coursework completed
Bachelor's degree
Master's degree
Doctorate
Name of High school
Most recent employer
Job title
Start date
Duties
Supervisor name
Salary (per month)
Are you currently working for this employer?
Yes
No
Second most recent employer
Job title
Start date
Duties
Supervisor name
Salary
End date
Reason for leaving
Third most recent employer
Job title
Start date
Duties
Supervisor name
Salary
End date
Reason for leaving
Reference 1: First & Last Name
Email address
Phone number
Years known
Address
Reference 2: First & Last Name
Email address
Phone number
Years known
Address
Reference 3: First & Last Name
Email address
Phone number
Years known
Address
Please attach your resume
Please select a file
Delete file
Please attach your Cover Letter
Please select a file
Delete file
Date of Birth
Driver License State
Driver License Number
I, hereby authorize Synergetics DCS, Inc. and/or its agents to make an independent investigation of my background, references, character, past employment, education, credit history, criminal or police records, including those maintained by both public and private organizations and all public records for the purpose of confirming the information contained on my Application and/or obtaining other information which may be material to my qualifications for employment now and, if applicable, during the tenure of my employment with Company.
NOTE:
The above information is required for identification purposes only, and is in no manner used as qualifications for employment. Synergetics DCS, Inc. is an Equal Opportunity Employer, and does not discriminate on the basis of Sex, Race, Religion, Age (40 and over), Handicap or National Origin