Application For Employment

Name:*
Phone:*
-
Date:*
E-mail:*
Address:
Position Desired*
Hours - Available From
 : 
Hours - Available Until
 : 
Are you a Citizen of the United States or do you have legal right to be employed in the United States?*
If not a Citizen of the United States, can you provide proof that you can legally be employed in the United States?
Have you ever been convicted of a felony? If yes, we are sorry, but BRG does not employ individuals with felonies on their record.*
How did you hear about BRG?
If referred, by whom?
Have you ever worked for BRG?*
Are you 17 years of age or older?*
Time of Employment Desired (Check all that apply)
Days Available (Check all that apply)

Education - High School

Name of High School Institution
Location of High School Institution
Diploma / Degree
Major Field of Study

Education - Graduate

Name of Graduate Institution
Location of Graduate Institution
Graduate Diploma / Degree
Graduate Major Field of Study

Education - College

Name of College Institution
Location of College Institution
College - Diploma / Degree
College - Major Field of Study
Have you ever had any experience in Telephone Research?
If yes, please explain
Please list any other skills that you think will assist us in determining your qualifications for this position
Have you ever had any experience in Data Entry or Coding?
What is your typing speed (wpm)?
What is your 10-key speed (wpm)?
Other than English, are there any other languages you are FLUENT in?
If yes, please list all languages you are FLUENT in

Most Recent Employment

Employer Name
Employer Phone
-
Employer Address
Supervisor Name and Title
Please detail the duties and requirements of your position
Starting Date
Starting Wage
 $ 
 . 
Ending Date
Ending Wage
 $ 
 . 
Reason for leaving

Previous Employment (Prior to Most Recent)

Employer Name (Prior to Most Recent)
Employer Phone (Prior to Most Recent)
-
Employer Address (Prior to Most Recent)
Supervisor Name and Title (Prior to Most Recent)
Please detail the duties and requirements of your position (Prior to Most Recent)
Starting Date (Prior to Most Recent)
Starting Wage (Prior to Most Recent)
 $ 
 . 
Ending Date (Prior to Most Recent)
Ending Wage (Prior to Most Recent)
 $ 
 . 
Reason for leaving (Prior to Most Recent)

Provide TWO references, preferably former or current employer(s). If not an employer please provide TWO references that are of NO RELATION to you.

First Reference

First Reference Name:*
First Reference Phone:*
-
First Reference - How do you know this person?*

Second Reference

Second Reference Name:*
Second Reference Phone:*
-
Second Reference - How do you know this person?*

JOB APPLICANT'S ACKNOWLEDGMENT AND AUTHORIZATION

I certify that all information provided by me herein are true and complete to the best of my knowledge. I authorize full investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand that false or misleading information, or omission of, given in my application or any interview(s) may result in discharge. I also understand that I will be required to abide by all rules, regulations, the policies and procedures of BRG Research Services.

By filling in my name below, I acknowledge that I have read, understood, and agree to the above statements.*
Agreement Date:

BRG Research Services, Inc. is an Equal Opportunity Employer. Applicants are considered for all positions without regard to political affiliation, religion, gender, race, color, national origin, sexual orientation, ability, marital or veteran status, the presence of an on-job-related medical condition of handicap, or other status protected under the local, State or Federal laws.

Verification: