REQUIRED FIELDS *
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Personal
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First Name:* | |
Middle Name:* | |
Last Name:* | |
Address:* | |
City:*
State: *
Zip:*
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Primary Phone:* | (area code) - |
Secondary Phone: | (area code) - |
E-mail:* |
Please double check your e-mail address |
Prior Address: | |
City:
State:
Zip:
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Are You at least 18 years of age?*
YES
NO
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How did you hear about us?*
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If an employee or associate of this company referred you to us, Please provide their name:
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Select your current status with this company *
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Have you applied to this company before?*
YES
When?
NO
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General Availability * |
Any * | Yes No |
Weekdays * | Yes No |
Weekends * | Yes No |
Early Mornings * | Yes No |
Mid - Day * | Yes No |
Afternoons * | Yes No |
Evenings * | Yes No |
Overnights * | Yes No |
Available Start Date:* |
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Experience/Skill Level |
Do you regularly provide independent contractor services to other businesses or individual?*
Yes
No
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Would contracting with MicahTek as an independent contractor prohibit you from providing similar contract services to any other businesses or individual?*
Yes
No
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(Range of Experience: Beginner: 0-6 months; Intermediate: 6 months - 2 years; Advanced: 2years or more) |
Call Center * |
Beginner
Intermediate
Advanced
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Inbound Order Processing * |
Beginner
Intermediate
Advanced
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Typing * |
Beginner
Intermediate
Advanced
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Data Entry * |
Beginner
Intermediate
Advanced
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Bilingual/Spanish * |
No
Speaks Some Spanish
Fluent Spanish Speaking
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Job Related Skills |
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Equipment Required |
Home Computer * |
PC
MAC (MAC not supported by our systems)
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Processor * |
500 MHZ or Higher
Less than 500 MHZ
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RAM * |
128 MB or more
Less than 128 MB
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Software * |
Word Version* Excel Version* |
Operating System * |
Windows 7
Other
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Internet Connectivity * |
DSL
Cable
Other Broadband
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Internet * |
Explorer 5.0 or newer
Other
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Email-Are you capable of receiving & sending attachments? *
Yes
No
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Land-Based Phone Line(Without call waiting) *
Yes
No
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Brand of Headset (Not Wireless):*
No headset
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If offered a contract, will you agree to have all of the required equipment operational before the start of the certification process?*
Yes
No
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Work Environment |
Will your working environment be quiet and free of background noise?*
Yes
No
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Employment/Contractor History |
Authorization to Contact this Employer?
Yes
No
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Authorization to Contact this Employer?
Yes
No
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Authorization to Contact this Employer?
Yes
No
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Personal References (Not Former Employers or Relatives) |
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Education |
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Affirmative Action |
This information is being gathered for affirmative action under Section 503 of the Rehabilitation Act of 1973. The information requested is voluntary and will be kept confidential. An applicant will not be subject to any adverse treatment for refusing to complete the questionnaire. |
The purpose of this section is to assist in monitoring Affirmative Action Programs and to aid in complying with any required Government record keeping or periodic reporting. This information is not part of your contractor application, and will not be considered in the contractor/selection process. If you choose to provide the information, please complete the following:
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RACE/ETHNICITY (check one) |
Other
American Indian - or Alaskan native
White - (not of Hispanic origin)
Black - (not of Hispanic origin)
Hispanic
Asian - or Pacific islander
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GENDER |
Male
Female
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VETERAN/U.S. MILITARY STATUS |
Special Disabled Veteran
- A veteran who is entitled to compensation under laws administered by the Department of Veteran affairs for a disability (a) rated at 30% or more, or (b) rated at 10% or 20% if it has been determined that the individual has a serious disability; or
- A veteran who was discharged or released from active duty because of a service-connected disability.
Other Protected Veteran
- Other protected veteran is defined as a veteran who served in the military, ground, naval or air service of the U.S. on active duty during a war or in a campaign or expedition for which a campaign badge has been authorized.
Non - Veteran
Vietnam Era Veteran
- Served in the military, ground, naval or air service of the U.S. on active duty for a period of more than 180 days, and was discharged or released from there with other than a dishonorable discharge, if any part of such active duty occurred: (a) in the Republic of Vietnam between 02/28/1961, and 05/07/1975; or (b) between 08/05/1964, and 05/07/1975, in all other cases; or
- Was discharged or released from active duty for service connected disability if any part of such active duty was performed: (a) in the Republic of Vietnam between 02/28/1961, and 05/07/1975; or (b) between 08/05/1964, and 05/07/1975, in all other cases.
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Security |
Applicant is not obligated to disclose any reference to a pre or post trial diversion program, any conviction which has been sealed, expunged or erased by the court, or, if in California, any marijuana related misdemeanor conviction entered more than two years prior to the date of this application.
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Have you ever been convicted of a felony in the past seven years?*
Yes
No
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If so, please provide details |
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Certification and Release |
I certify that the answers given by me to the foregoing questions and statements made by me are complete and true to the best of my knowledge and belief.
I understand that any false information, omissions or misrepresentations of facts called for in this application, whether on this document or not, may result in rejection of my application or termination of contract at any time.
I authorize the company and/or its agents, including consumer reporting bureaus, to verify any of this information.
I also understand that the use of illegal drugs is prohibited while executing my duties as outlined by the contract agreement.
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Please check if you agree.* |
Notice and Disclosure |
Disclosure to Applicant
Regarding Procurement of a Consumer Report
As required by the Fair Credit Reporting Act, this is to advise you that in connection with your application for contract, as part of the process for consideration, we may procure a consumer report on you regarding your character, general reputation, personal characteristics, or mode of living. If the information from the report is used in whole or in part, to make an adverse decision we will provide you with a copy of the consumer report and a description in writing of your rights under the law before making an adverse decision.
We may also obtain an investigative report including information as to your character, general reputation, personal characteristics and mode of living. We may obtain this information by contacting your previous employers or references supplied by you. You have the right to make a written request within a reasonable time that we provide a complete and accurate disclosure of the nature and scope of the information requested. Such disclosure will be made to you as soon as administratively possible once we receive the request from you, or after the report was first requested.
The Fair Credit Reporting Act gives you specific rights in dealing with consumer reporting agencies. You will find these rights summarized on a Summary of Your Rights Under the Fair Credit Reporting Act. See Attachment A
By submitting this application, you hereby authorize us to obtain a consumer report about you in order to consider your application for contractor status.
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Release Authorization |
In connection with my application for contractor status, I understand that a background investigation report may be requested that will include information as to my character, work habits, performance, and experience, along with reason for termination of past employments/contracts. I understand that as directed by company policy and consistent with the job duties outlined by the contract agreement, you may be requesting information from public and private sources about my: workers' compensation injuries, criminal record, driving record, court record, education, credentials, credit, and references.
Medical and workers' compensation information will only be requested in compliance with the federal Americans with Disabilities Act (ADA) and/or any other applicable state laws. According to the Fair Credit Reporting Act, I am entitled to know if my application for contractor status is denied because of information obtained by the company from a consumer reporting agency. If so, I will be notified and given the name and address of the agency or the source that provided the information.
I hereby authorize, without reservation, any law enforcement agency, institution, information service bureau, school, employer, reference or insurance company contacted by MicahTek, Inc or its agent, to furnish the information described in this application. The following information is required by law enforcement agencies and other entities for positive identification purposes when checking public records. It is confidential and will not be used for any other purposes. I hereby release the employer and agents and all persons, agencies, and entities providing information or reports about me from any and all liability arising out of the request for or release of any of the above-mentioned information or reports.
By completing and submitting this application, you hereby authorize us to obtain a background investigative report about you in order to consider you for application for contractor status.
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