PLEASE PRINT ALL INFORMATION REQUESTED EXCEPT SIGNATURE JMA SERVICE PROVIDER APPLICATION PLEASE COMPLETE ALL PAGES Date _________________________________ Name ________________________________________________________________________________________B_____ Last First Middle Initial Present address __________________________________________________________________________________B__ Number Street City State Zip How long at Present Address _____________BBB__________ Social Security No. __B__________BB_BBBBBBB_______ Home PhoneBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB Cell Phone BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB If under 18, please list age ______ Date available for work? _______BBBBBBBBBBBBBB_________ Email Address: _______________________________________________________________BBBBBBB_________________ TYPE OF SCHOOL NAME OF SCHOOL EDUCATION LOCATION (Complete mailing address) NUMBER OF YEARS COMPLETED MAJOR & DEGREE High School College Bus. or Trade School Professional School No HAVE YOU EVER BEEN CONVICTED OF A FELONY? Yes If yes, please explain. _________________________________________________________________________________ ___________________________________________________________________________________________________ MILITARY HAVE YOU EVER BEEN IN THE ARMED FORCES? ARE YOU NOW A MEMBER OF THE NATIONAL GUARD? Yes No Yes No Specialty __________________________________ Date Entered ________________ Discharge Date ______________ ___________________________________________________________________________________________________________ JM Adjustment Services, LLC 16600 18 Mile Road, Clinton Township, Michigan 48038 Phone: 586.739.1200 Website: www.jmadjustment.com Email: [email protected] PLEASE PRINT ALL INFORMATION REQUESTED EXCEPT SIGNATURE Work Experience JMA SERVICE PROVIDER APPLICATION Please list your two most recent positions. If you were self-employed, give firm name. Name of employer Employment dates Name of last supervisor Address City, State, Zip Code From Phone number To <RXU/DVW-RE7LWOH Reason for leaving (be specific) Name of employer Employment dates Name of last supervisor Address City, State, Zip Code From Phone number To Your Last Job Title Reason for leaving (be specific) May we contact your present employer? Yes No Did you complete this application yourself Yes No If not, who did? ______________________________________________________________________________________ AGREEMENT (PLEASE READ CAREFULLY BEFORE SIGNING) I certify that all the information on this application is accurate and complete to the best of my knowledge and understand that misleading or false statements will constitute sufficient cause for refusal of hire or termination. I understand that neither the acceptance of this application nor the subsequent entry into a service provider relationship with J.M. Adjustment Services, LLC creates an actual or implied contract. I understand that, if I become a service provider with J.M. Adjustment Services, LLC, it will be on an at-will basis. This means that either J.M. Adjustment Services, LLC or I have the right to terminate the relationship at any time, for any reason, with or without cause. I agree to submit to drug testing and a national background check prior to my being utilized as a service provider by J.M. Adjustment Services, LLC. I release J.M. Adjustment Services, LLC, and its employees, plus other persons or companies, from any and all liability arising out of or related in any way to such testing. I authorize J.M. Adjustment Services, LLC to investigate information concerning my education, employment experiences and all other aspects of my background relevant to my becoming a service provider. I release J.M. Adjustment Services, LLC and its employees from all liability arising from such investigation. Signature of applicant__________________________________________ Date: ___________________ J.M. Adjustment Services, LLC is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity with J.M. Adjustment Services, LLC depends solely on your qualifications. Please Fax / Email Complete Application to: Fax: 586.739.6900 Email: [email protected] Click Here to Submit Your Application by Email (requires Acrobat 8 or higher)
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