I. BUSINESS EXPERIENCE: (Please start with your present or most recent position.) REMINDER: DO NOT COMBINE JOBS — FILL OUT A COMPLETE SECTION OF THIS FORM FOR EVERY JOB WHERE JOB TITLE CHANGED.

Staff: Number of direct reports

Immediate Supervisor

Supervisor Email or Phone

What is your best guess as to how this supervisor would rate your overall performance?

If rating is impossible to provide, please explain:

What do (did) you like most about your job?

What do (did) you least enjoy?

If you are leaving or have left the company, please indicate your motivation to leave.

100% Mine Mutual 100% Company’s (I was fired) Options don’t fit circumstance

If options don’t fit circumstance, please explain:

Reason(s) for leaving:

Supervisor Email or Phone

II. MILITARY EXPERIENCE:

If in service, indicate branch:

College/Graduate School

Extracurriculars, Honors, Awards

College/Graduate School

Extracurriculars, Honors, Awards

Membership in professional or job-relevant organizations (You may exclude groups that indicate race, color, religion, national origin, disability, or other protected status.)

Publications, patents, inventions, professional licenses, or additional special honors or awards

What qualifications, abilities, and strong points will help you succeed in this job?

What are your weak points and areas for improvement?

V. CAREER NEEDS:

Willing to relocate?

Amount of overnight travel acceptable:

What are your career objectives?

VI. RATINGS BY BOSSES:

If you were to be asked to arrange calls with bosses you’ve had in the past 8 years, what is your best guess as to how they would rate you (the rating scale is:
5 = Excellent, 4 = Very Good, 3 = Good, 2 = Fair, 1 = Poor) on the following:

Judgment/Decision Making

Resourcefulness/Initiative

Do you have the legal right to work for any employer in the United States?

Yes No

Would you be willing to arrange reference calls with supervisors you’ve had in the past decade, as a last step before a final job offer?

Yes No

I certify that the answers given in this Career History Form are true, accurate, and complete to the best of my knowledge. I authorize an investigation into all statements I have made on this Form as may be necessary for reaching an employment decision. I understand that I may be asked to arrange reference calls with managers I’ve worked for. In the event I am employed, I understand that any false or misleading information I knowingly provided in my Career History Form or interview(s) may result in discharge and/or legal action. I understand that if employed, I am required to abide by all rules and regulations of the employer and any special agreements reached between the employer and me.

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