Associate Registration PERSONAL INFORMATION First Name * (as it appears on your social security card of valid ID) Last Name * Address City State Select State AlaskaAlabamaArkansasAmerican SamoaArizonaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaFederated States of MicronesiaGeorgiaGuamHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMarshall IslandsMichiganMinnesotaMissouriNorthern Mariana IslandsMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaPuerto RicoPalauRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVirgin IslandsVermontWashingtonWisconsinWest VirginiaWyoming Zip Phone * Email Are you a U.S Citizen? Yes No Have you ever been convicted of a felony? Yes No If selected for employment are you willing to submit to a pre-employment drug screening? Yes No Social Security Number Date of Birth Picture of ID If you have trouble uploading your ID, please email it to sheri.dickert@thevsrg.com POSITION Position you are applying for Available Start Date Desired Pay Employment Desired Full Time Part Time Seasonal/Temporary EDUCATION School Name Location Years Attended Degree Received Major School Name ( 1 ) Location Years Attended Degree Received Major School Name ( 2 ) Location Years Attended Degree Received Major School Name ( 3 ) Location Years Attended Degree Received Major School Name ( 4 ) Location Years Attended Degree Received Major REFERENCES Name Title Company Phone Email Name ( 1 ) Title Company Phone Email Name ( 2 ) Title Company Phone Email Name ( 3 ) Title Company Phone Email Name ( 4 ) Title Company Phone Email EMPLOYMENT HISTORY Employer ( 1 ) Job Title Dates Employed Work Phone Starting Pay Rate Ending Pay Rate Address City State Select State AlaskaAlabamaArkansasAmerican SamoaArizonaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaFederated States of MicronesiaGeorgiaGuamHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMarshall IslandsMichiganMinnesotaMissouriNorthern Mariana IslandsMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaPuerto RicoPalauRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVirgin IslandsVermontWashingtonWisconsinWest VirginiaWyoming Zip Email Employer ( 2 ) Job Title Dates Employed Work Phone Starting Pay Rate Ending Pay Rate Address City State Select State AlaskaAlabamaArkansasAmerican SamoaArizonaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaFederated States of MicronesiaGeorgiaGuamHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMarshall IslandsMichiganMinnesotaMissouriNorthern Mariana IslandsMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaPuerto RicoPalauRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVirgin IslandsVermontWashingtonWisconsinWest VirginiaWyoming Zip Email Employer ( 3 ) Job Title Dates Employed Work Phone Starting Pay Rate Ending Pay Rate Address City State Select State AlaskaAlabamaArkansasAmerican SamoaArizonaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaFederated States of MicronesiaGeorgiaGuamHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMarshall IslandsMichiganMinnesotaMissouriNorthern Mariana IslandsMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaPuerto RicoPalauRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVirgin IslandsVermontWashingtonWisconsinWest VirginiaWyoming Zip Email Employer ( 4 ) Job Title Dates Employed Work Phone Starting Pay Rate Ending Pay Rate Address City State Select State AlaskaAlabamaArkansasAmerican SamoaArizonaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaFederated States of MicronesiaGeorgiaGuamHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMarshall IslandsMichiganMinnesotaMissouriNorthern Mariana IslandsMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaPuerto RicoPalauRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVirgin IslandsVermontWashingtonWisconsinWest VirginiaWyoming Zip Email Employer ( 5 ) Job Title Dates Employed Work Phone Starting Pay Rate Ending Pay Rate Address City State Select State AlaskaAlabamaArkansasAmerican SamoaArizonaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaFederated States of MicronesiaGeorgiaGuamHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMarshall IslandsMichiganMinnesotaMissouriNorthern Mariana IslandsMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaPuerto RicoPalauRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVirgin IslandsVermontWashingtonWisconsinWest VirginiaWyoming Zip Email RESUME Upload your resume (optional) SIGNATURE DISCLAIMER I certify that my answers are true and complete to the best of my knowledge. If this application leads to employement, I understand that false or misleading information in my application or interview may result in my release. Signature Please enter your full name. Date Please enter your full name. Submit
