JMA SERVICE PROVIDER APPLICATION

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)