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PLEASE COMPLETE ENTIRE APPLICATION, USING DARK INK OR A TYPEWRITER TO ENSURE PROCESSING (If entering on-line, use 8 pt. Type – Arial font)

|(Print) Last Name |First Name |Middle Initial |Social Security No. |Today’s Date |

|      |      |      |      |      |

|List All Your Previous Names Under Which Employment or Education May Be Verified |E-mail Address |

| | |

| |      |

|      | |

|Current Address (Use Complete Mailing Address with County & Zip Code) |Phone No. with Area Code |

|       |      |

|Permanent Address (with County) |Phone No. with Area Code |

|      |      |

|Previous Address (with County) |

|      |

|      |

C A R E E R

|Position/Type of Work Desired |Please Put an “X” in a Box Below |

|      | Full Time Part Time Shift Work Temporary Summer |

|How Did You Hear of This Position/Company? |Date Available for Employment |

|      |      |

|Do you have any relevant experience for the job you applying for? If so please list. |

| |

E D U C A T I O N (Must be filled out for consideration – do not refer to resume)

|Type of School |Name of School (with City/State) |Major Field |Dates Attended |Years |Degree (Including Mo./Yr. Granted or |

| | |of Study |(From Mo./Yr. |(Completed) |Expected) |

| | | |To Mo./Yr.) | | |

|College or | | | | | |

|University |      |      |      |      |      |

|Graduate or other | | | | | |

|Formal Education |      |      |      |      |      |

|Scholastic Honors/Scholarships | |

|(Indicate at Right) |      |

A D D I T I O N A L D A T A

|Have You Been Convicted of any Crime other than a Minor|Date(s) |Place(s) |Charge(s) |

|Traffic Violation? A conviction will not necessarily | | | |

|disqualify you. | | | |

| |      |      |      |

|Yes No | | | |

|Do You Have the Right to Work in the U.S.? (Please check the correct box at the right) Yes No |

|What computer programs or software are you familiar with? |

| |

|Please provide any additional information such as special skills, training, management experience, equipment operation, or qualifications you feel will be helpful|

|to us in considering your application: |

| |

E M P L O Y M E N T H I S T O R Y (Must be filled out for consideration – do not refer to resume)

|Are you employed now? (Indicate at Right) | Yes No |

|May We Contact Your Present Employer? (Indicate at Right) | Yes No |

|If presently employed, why do you desire to change your position? | |

| Please give complete & detailed information regarding your present & former employment (exclude military service) to ensure application processing. Indicate |

|with an “X” whether the position was full-time, part-time, or summer employment. |

| |From |To |Full-time |Part-time |

|      |      |      |      |      |

G E N E R A L

|Have you previously applied, interviewed, or been employed by QPSI? (Check the appropriate box below & then, if “Yes”, provide us with specific information |

|including dates & locations of where you applied, interviewed, or were employed. |

| Yes No |      |

|Are you 18 years of age or older? |Do You Have a Valid Driver’s License? |State |License No. |

|      | Yes No |      |      |

|Preferred Salary |Minimum Salary |

| | |

R E F E R E N C E S – Include two professional references & 1 personal reference - do not include Supervisors listed above or relatives.

|Name & Title (if personal, indicate relationship) |Best way to reach each reference |Years known |

| |(day/evening phone no., e-mail address, other) | |

|      |      |      |

|      |      |      |

|      |      |      |

| (Please check this box to certify that all information given on this application is true & correct. DO NOT SUBMIT YOUR SHEET WITHOUT |

|CHECKING THIS BOX) |

| |

|I certify that all information given on this application is true and correct. I understand that QPSI or any third-party investigation company retained by QPSI may|

|make an investigation of my work & personal history and I authorize all persons, schools, companies, corporations, credit bureaus & law enforcement agencies to |

|supply any information concerning my background and release them from any liability & responsibility rising from their doing so.  And if hired, my employment |

|would be “at will” which means I may be terminated at any time for any or no reason.  Any change to the policies stated above must be in writing & signed by the |

|CEO/ President and/or designee of the Company in order to be effective.    |

|Applicant’s Signature |Date |

|      |      |

This statement may be photocopied for background investigation. NOTE: Your application will be kept active for one year after submission.

Equal Opportunity: We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non-job-related medical condition or handicap, or any other legally protected status.  We will give this application every consideration. However, in accepting it, the Company makes no commitment of employment to the applicant.  This application will remain active for six months.

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Personal Data Sheet

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