Form Can Only Be Completed in INTERNET EXPLORER. DO NOT use FIREFOX or CHROME

Cell Phone Mandatory

First Name:*

Last Name:*                                                                  

Address:*

City:*

State:*

Zip:*

Phone Number:*

Cell Number:*

E-Mail Address:*

Available Start Date:*

Mileage Radius you can cover from your home zip code:* 20 30 40 50 70

Do you have computer experience?*YesNo

Do you have high speed Internet?*YesNo

Do you have a digital camera?*YesNo

Highest Level of Education:*Primary School High School Some College Bachelors

If you earned a college degree, please list major:

Are You Authorized to Work in the United States and can you provide proof?*YesNo

Have you ever been Convicted of a Felony?*YesNo

Would you be willing to Submit to a background check?*YesNo

Current Employer:

Dates Employed:

Supervisor Name:

Phone:

Job Duties:

Previous Employer:

Dates Employed:

Supervisor Name:

Phone:

Job Duties:

I Agree By checking here I understand I am a Independent Contractor and will receive a 1099 at end of year.*

I Agree By checking here I understand that if I have falsified any information on this form it may result in immediate termination of any contract with Field Reporters For Hire LLC*