Information Capture Solutions

Information Capture Solutions is an equal opportunity employer.

All statements made by applicants for employment on this application form will be checked for accuracy. We offer equal employment opportunities to all persons without discrimination on the basis of race, color, religion, age, sex, national origin, citizenship status, physical or mental disability, or past, present, or future service in the Uniformed Services of the U.S. or any other legally protected status. The use of this form does not mean there are positions open and does not obligate us in any way.

Your Details

Name *

First

Last

Email *

Phone *

Current Address *

Address Line 1

Address Line 2

City

State

Zip Code

Previous Address (If at current address for less than one year)

Address Line 1

Address Line 2

City

State

Zip Code

Social Security Number

Are you at least 18 years of age? *

Yes
No

Employment is subject to verification of minimum legal age.

Can you produce documented proof of your identity and eligibility for employment in the United States? *

Yes
No

Examples: driver’s license, Social Security card, birth certificate, and/or Immigration and Naturalization Service Documents.

Name of Emergency Contact *

First

Last

Who should we contact in case of an emergency?

Emergency Contact Phone *

Position Details

Position Applying For *

How soon could you report to work? *

Type of employment desired: *

Full-Time
Part-Time
Temporary

If part-time, what days & hours are you available to work? *

Rate of pay expected:

If you have a resume, you may upload it here in PDF format (optional):

Click or drag files to this area to upload. You can upload up to 3 files.

You may upload your resume in PDF format.

Education Details

Name of the High school you attended: *

Where is the High school located? (City, State) *

Please select the highest grade of non-college education completed *

Did you attend college? *

Yes
No

Name of the College you attended: *

Where is the College located? (City, State) *

Please select the highest year of college education completed: *

Did you receive a college degree? *

Yes
No

Please list your college degree: *

Application & Employement Details

Have you applied for a job with us before? *

Yes
No

Have you ever worked for us before? *

Yes
No

How did you come to apply? *

Name of Employee that referred you? *

First

Last

Please explain how you came to apply: *

Have you ever been bonded? *

Yes
No

Have you ever been refused a bond? *

Yes
No

If yes, please explain the reason and provide the date of bond refusal:

Have you ever been convicted of a violation of the law except a minor traffic violation? *

Yes
No

A conviction will not necessarily disqualify you from employment.

If yes, please provide the date, name of the court, and location where the offense occurred. *

Have you ever been discharged or requested to resign from a position? *

Yes
No

Are you currently employed? *

Yes
No

If yes, may we contact your current employer? *

Yes
No

Have you ever held a position of trust (handling money or confidential material)? *

Yes
No

If yes, please describe: *

Do you have any reason to believe that you would have difficulty meeting this company's work schedules? *

Yes
No

Please provide any additional information such as special skills, training, experience, equipment operation, or other qualifications you feel will be helpful to us in considering your application:

Employment History

Company / Business Name of most recent employer: *

Name of Supervisor at most recent employer: *

First

Last

Address of most recent employer: *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number for most recent employer: *

Date Hired: *

If not sure of exact date, please make your best estimate.

Are you still employed with this company? *

Yes
No

Date Left: *

If not sure of exact date, please make your best estimate.

Starting pay rate:

Current / Final pay rate:

Please provide your job title, along with a description of your duties & responsibilities: *

Please provide your reason for leaving: *

May we contact this employer? *

Yes
No

Company / Business Name of 2nd most recent employer:

Name of Supervisor at 2nd most recent employer:

First

Last

Address of 2nd most recent employer:

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number for 2nd most recent employer:

Date Hired:

If not sure of exact date, please make your best estimate.

Are you still employed with this company?

Yes
No

Date Left:

If not sure of exact date, please make your best estimate.

Starting pay rate:

Current / Final pay rate:

Please provide your job title, along with a description of your duties & responsibilities:

Please provide your reason for leaving:

May we contact this employer?

Yes
No

Company / Business Name of 3rd most recent employer:

Name of Supervisor at 3rd most recent employer:

First

Last

Address of 3rd most recent employer:

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number for 3rd most recent employer:

Date Hired:

If not sure of exact date, please make your best estimate.

Are you still employed with this company?

Yes
No

Date Left:

If not sure of exact date, please make your best estimate.

Starting pay rate:

Current / Final pay rate:

Please provide your job title, along with a description of your duties & responsibilities:

Please provide your reason for leaving:

May we contact this employer?

Yes
No

Data Entry Experience

Are you applying for a data entry position?

Yes
No

How many years have you worked in a data entry environment? *

Who have you worked for previously? (Check all that apply) *

If other, please provide the name of the company:

How many words-per-minute can you type? *

If you are unaware of how many words-per-minute you can type, please take a free typing test at https://official-typing-test.com/test/3test.html then enter your results here.

What was your average quality rate? *

What types of jobs have you keyed on? (Check all that apply) *

If other, please provide the type of job: *

Please check any other data conversion experience you may have:

Job Applicant’s Agreement and Certification *

I agree

“I certify that the information given by me in this application is true in all respects, and I agree that if the information given is found to be false in any way, it shall be considered sufficient cause for denial of employment or discharge. I authorize the use of any information in this application to verify my statements, and I authorize past employers, all references, and any other persons to answer all questions asked concerning my ability, character, reputation, and previous employment record. I release all such persons from any liability or damages on account of having furnished such information.”

“I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between the company and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me and I understand that no such promise or guarantee is binding upon the company unless made in writing. If an employment relationship is established, I understand that I have the right to terminate my employment at any time and that the company retains the same right.”

“If I am offered employment, I agree to submit to a physical examination whenever requested, and I understand my becoming employed and/or my continued employment is subject to the results of any physical examination related to my job duties. In accordance with company policies and procedure.”

“I understand that if employed, policies, and rules which are issued are not conditions of employment and that the employer may revise policies or procedures in whole or part, at any time.”

“I understand that this application will be kept on active file for a limited number of days from the date completed, after which time I would have to reapply in accordance with established company procedures.”

Applicant's Full Name *

First

Middle

Last

Date *

Apply Now!