Fields in RED are required  
First Name:
  
Last Name:
  
Address:
  
  (No PO Boxes - use your actual address)  
City:
  
State:
  
Postal/Zip Code:
  
Home Phone:
        
Work Phone:
May we call you at work?
  
Cell Phone:
        
Other Phone:
        
Best Time to Call:
    
Fax Phone:
 (We will contact you before using your fax number)  
Email:
  
       
Referred By:
  
  Please provide the name of your Referrer so we can thank them:  
  Referrer's Name:  
     
Occupation:
  
Education:
  
Age Group:
  
Closest City:
  
Surrounding Area:
 (i.e. North of Boston, South of Dallas, etc.)  
 
Are you aware of a specific location of one of our clients
that you would be interested in evaluating? Please tell us the location.
Client Location: 		 
       
    Are you available for Lunch Duty?  
    What days / times are you available for assignments?
Please be specific about days & times.
For example, Mon thru Fri from 11am to 3pm and Sun evenings. 		 
       
    Do you have a computer to prepare reports?  
    Do you use MS Word?  
    Are you able to Receive, Open, and Return Email Attachments?  
       
    Do you perform these types of assignments for other companies?  
    If YES, how long have you been accepting assignments?
  
    If YES, please list the type of assignments you perform.
(You do not need to disclose the companies or locations)

  
       
    Some assignments require alcohol consumption. Is this acceptable?  
   
 If you are selected for an assignment, do you agree to maintain the  confidentiality of ServiceSense and all of our clients?
 
       
     
     

 
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Phone: 800.465.1182 • Fax: 800.465.1183 • Email: Info@ServiceSense.com