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Blake & Associates Confidential Application
Date: / / Last Name First Name Middle Initial Birthdate / /
Address: City State Zip
Present Employer Name Present Employer Address
Home Phone Business Phone Emergency Phone
SSN School Years Completed Relocation Yes

No

Car Yes No License #
EDUCATION

Name of School
City
Years Attended
Hours Completed
Major / Other
Grade Average
Degree
High School

Fr / /
To / /

College
Fr / /
To / /
Other
Fr / /
To / /
List of Professional & Other Organizational Memberships
How was your schooling financed?
Military Work History
Branch of Service Actual Dates
Fr / /
To / /
Rank When Discharged Security Clearance Special Training
Work History (Present or Most Recent First)
Dates Started
Employer Name
Address, City
Phone
Product or Service
Position / Salary
Why Did you Leave?
Fr / /
To / /
Fr / /
To / /
Fr / /
To / /
Fr / /
To / /
The Following Information Is Needed In order To Better Serve You.
List Below Three Persons Who are Familiar With Your Work
Name
Address / City
Phone No.
Occupation
1.
2.
3.
Personal References
Name
Address / City
Phone No.
Occupation
1.
2.
3.
So we will not contact the same Companies you have interviewed with or will be interviewing with, list them below
Company Name
Interviewed by
Position Open
Interview Date
1.
/ /
2.
/ /
3.
/ /
4.
/ /
5.
/ /
6.
/ /
Please List other Agencies you have been to
1.
2.
3.
Hobbies and / or Special Interests
1.
2.
3.
4.
List six functions that you perform on your present or previous job
1.
2.
3.
4.
5.
6.
List five qualities which you feel will help you in the position you desire
1.
2.
3.
4.
5.
Blake & Associates Agency
1. ACCEPTANCE OF POSITION I agree to notify BLAKE & ASSOCIATES AGENCY of the results of all interviews obtained through their efforts and to notify BLAKE & ASSOCIATES AGENCY within 24 hours of any offer and acceptance of any position with any company referred by BLAKE & ASSOCIATES AGENCY within six (6) months of date of referral.
2. OBLIGATION It is UNDERSTOOD that I ASSUME NO FINANCIAL OBLIGATION TO BLAKE & ASSOCIATES UNLESS: UNDER N.J.S.A 34:8-32 Paragraph (6) and (7). (6) CHARGE to APPLICANT who FAILS to report for duty, after ACCEPTING employment is not more than two-fifths of the Scheduled fee. (7) CHARGE to APPLICANT who LEAVES employment of his/her own accord, within the first week, or before EMPLOYER'S TIME OF GUARANTEE HAS EXPIRED is not more than two-fifths of Scheduled fee
3. DISCLOSURE STATEMENT I consent to BLAKE & ASSOCIATES AGENCY checking my previous employer, school and other references and giving such information to any perspective employers. I understand that such information may include my character, general reputation, personal characteristics, mode of living and financial responsibility. This information may be furnished to prospective employer by BLAKE & ASSOCIATES AGENCY with no liability on the part of BLAKE & ASSOCIATES AGENCY. I retain the right to request of BLAKE & ASSOCIATES AGENCY to learn the complete nature and scope of this report.
This agency is licensed by the Bureau of Employment Agencies,
Department of Consumer Affairs, State of New Jersey, Trenton.