Employee Data Form

An Equal Opportunity Employer

EMPLOYMENT - EDUCATION VERIFICATION & RELEASE

* - Required Field

Date*:	Date of Birth*:
Last Name: First Name: Middle Name:
Street: City: State: Zip:
Home Phone: Mobile Phone*: Fax #:
E-Mail*:	Business Phone:
Company:	Title:
Positions Desired:
Job Category:	Salary Requirement:

Specific Days and Hours for which you are available:

EDUCATION:

	School Name	City/ ST	Degree Earned/Major	GPA	Year Completed
High School
College
Name used at enrollment / graduation:
Grad. School
Name used at enrollment / graduation:
Add'l Education
Name used at enrollment / graduation

EMPLOYMENT HISTORY:

Current / Most Recent:

Beginning Date:	Ending Date:
Beginning Salary:	Ending Salary:	Bonuses and Employment / Performance Incentives:
Company: Title: Address:
Telephone:	City: State: Zip:
Hours Worked:	Company Product:	Supervisor:
Skills Required: Duties Performed:
Reason for Leaving:

Beginning Date:	Ending Date:
Beginning Salary:	Ending Salary:	Bonuses and Employment / Performance Incentives:
Company: Title: Address:
Telephone:	City: State: Zip:
Hours Worked:	Company Product:	Supervisor:
Skills Required: Duties Performed:
Reason for Leaving:

Beginning Date:	Ending Date:
Beginning Salary:	Ending Salary:	Bonuses and Employment / Performance Incentives:
Company: Title: Address:
Telephone:	City: State: Zip:
Hours Worked:	Company Product:	Supervisor:
Skills Required: Duties Performed:
Reason for Leaving:

Beginning Date:	Ending Date:
Beginning Salary:	Ending Salary:	Bonuses and Employment / Performance Incentives:
Company: Title: Address:
Telephone:	City: State: Zip:
Hours Worked:	Company Product:	Supervisor:
Skills Required: Duties Performed:
Reason for Leaving:

Beginning Date:	Ending Date:
Beginning Salary:	Ending Salary:	Bonuses and Employment / Performance Incentives:
Company: Title: Address:
Telephone:	City: State: Zip:
Hours Worked:	Company Product:	Supervisor:
Skills Required: Duties Performed:
Reason for Leaving:

SUPERVISORY PROFESSIONAL REFERENCES

(Include Name, Position, Daytime Phone, Current Position, Current Company, E-Mail Address and a brief description as to how and when your professional backgrounds overlapped.)

CSI EXECUTIVE SEARCH -- RELEASE

Austin, TX	512.301.5559 FAX

PLEASE READ CAREFULLY BEFORE SIGNING

I authorize CSI EXECUTIVE SEARCH to investigate all statements in this Employment & Education Verification & Release and to secure any necessary information from all my employers, references, and academic institutions. I hereby release all of those employers, references, academic institutions, and CSI EXECUTIVE SEARCH from any and all liability arising from their giving or receiving information about my employment history, my academic credentials or qualifications, and my suitability for employment.

I understand that any offer of employment may be contingent upon receipt of a satisfactory report concerning my credit, academic credentials, social / emotional intelligence screening, employment references, and, depending on the position offered, physical examination. I further understand that any falsification, misrepresentation, or omission of information on this Employment & Education Verification & Release will be sufficient cause for rejection of my application if not yet employed by or through CSI EXECUTIVE SEARCH and for immediate dismissal if employed by or through CSI EXECUTIVE SEARCH. I also authorize CSI EXECUTIVE SEARCH to supply information about my employment record, in whole or in part, in confidence to any prospective employer, government agency, or other party having a legal or proper interest, and I hereby release CSI EXECUTIVE SEARCH from any and all liability for its providing this information.

I understand that ANY and ALL employment-related information (including but not limited to client company name, contact name, and position available) furnished by CSI EXECUTIVE SEARCH to me is CONFIDENTIAL. I agree not to accept a position or assignment that has been presented to me by CSI EXECUTIVE SEARCH, through any organization associated with CSI EXECUTIVE SEARCH's efforts, including the client company, without the prior direct discussion with CSI EXECUTIVE SEARCH.

Should I be unavailable to be reached to review a position or assignment, I authorize CSI EXECUTIVE SEARCH to submit my resume for consideration without my approval. I understand and acknowledge that, if hired, my status will be one of an "at will" employee. This means that I may resign at any time and that I may be terminated without cause as long as all local, state, and federal laws are not violated.

I hereby certify by my signature below that I have read, understood, and agree to the terms and conditions set forth above.

Signature: __________________________________ Date:

(REV. 01 07)

Date Available:	Are you willing to relocate?* Yes No
How were you referred to CSI EXECUTIVE SEARCH?
Are you authorized to work in the United States?* Yes No
Have you ever applied here before? Yes No If yes, specify the date(s):
Have you ever been employed here before? Yes No If yes, specify date(s):
Will anything prevent you from performing the essential functions of the position or positions in which you have expressed an interest to CSI with or without reasonable accommodation?* Yes No	If "yes", explain.
Are you at least 18 years of age?* Yes No (If you are under the age of 18, you may need to supply CSI EXECUTIVE SEARCH with a work permit or limit your hours to those permitted by law.)