MicahTek Contractor Application
OKLAHOMA RESIDENTS ONLY

REQUIRED FIELDS *

Personal

First Name:*
Middle Name:*
Last Name:*
Address:*
City:*    State: *   Zip:*
Primary Phone:* (area code)  -
Secondary Phone: (area code)  -
E-mail:* Please double check your e-mail address
Prior Address:
City:    State: Zip:
Are You at least 18 years of age?*             YES NO
How did you hear about us?*     
If an employee or associate of this company referred you to us, Please provide their name:           
Select your current status with this company *
Have you applied to this company before?* YES When?     NO

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:*

Experience/Skill Level

Do you regularly provide independent contractor services to other businesses or individual?*     Yes No
Would contracting with MicahTek as an independent contractor prohibit you from providing similar contract services to any other businesses or individual?*    Yes No
(Range of Experience: Beginner: 0-6 months; Intermediate: 6 months - 2 years; Advanced: 2years or more)
Call Center * Beginner Intermediate Advanced
Inbound Order Processing * Beginner Intermediate Advanced
Typing * Beginner Intermediate Advanced
Data Entry * Beginner Intermediate Advanced
Bilingual/Spanish * No Speaks Some Spanish Fluent Spanish Speaking
Job Related Skills

Equipment Required

Home Computer * PC MAC (MAC not supported by our systems)
Processor * 500 MHZ or Higher Less than 500 MHZ
RAM * 128 MB or more Less than 128 MB
Software * Word Version*    Excel Version*
Operating System * Windows 7      Other
Internet Connectivity * DSL Cable Other Broadband
Internet * Explorer 5.0 or newer     Other
Email-Are you capable of receiving & sending attachments? *     Yes No
Land-Based Phone Line(Without call waiting) *         Yes No
Brand of Headset (Not Wireless):*      No headset
If offered a contract, will you agree to have all of the required equipment operational before the start of the certification process?* Yes No

Work Environment

Will your working environment be quiet and free of background noise?*    Yes   No

Employment/Contractor History

Company Name - 1 Start Date
  Mo/Yr
End Date
  Mo/Yr
Weekly
Start
Salary
Weekly
Last
Salary
Reason for Leaving Name of Supervisor
Company Address Type of Business Position Held
Company Phone Number Describe the work you did
(area code)-
Authorization to Contact this Employer? Yes No


Company Name - 2 Start Date
  Mo/Yr
End Date
  Mo/Yr
Weekly
Start
Salary
Weekly
Last
Salary
Reason for Leaving Name of Supervisor
Company Address Type of Business Position Held
Company Phone Number Describe the work you did
(area code)-
Authorization to Contact this Employer? Yes No


Company Name - 3 Start Date
  Mo/Yr
End Date
  Mo/Yr
Weekly
Start
Salary
Weekly
Last
Salary
Reason for Leaving Name of Supervisor
Company Address Type of Business Position Held
Company Phone Number Describe the work you did
(area code)-
Authorization to Contact this Employer? Yes No

Personal References (Not Former Employers or Relatives)

Name Occupation Address Phone Number
(area code)-
(area code)-
(area code)-

Education

Name of High School Address Graduated? Highest Grade
Completed


Yes No
Year(optional)

Name of College, University
or Technical School
Address Major Field
of Study
Diploma, Degree or
Certificate Received
Date
Received
Credit
Hours

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:

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
GENDER Male Female
VETERAN/U.S. MILITARY STATUS
Special Disabled Veteran
  1. 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
  2. A veteran who was discharged or released from active duty because of a service-connected disability.
Other Protected Veteran
  1. 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
  1. 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
  2. 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.

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.

Have you ever been convicted of a felony in the past seven years?* Yes No
If so, please provide details

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.
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.

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.