Last Name:___________________________First:_______________________M.I.:________
Social Security Number:_________|______|_________
E-mail Address:____________________________________________
Address:__________________________________________________City:__________________________State:___________________________________ Zip:_________________ Country:___________________

Previous Address (If less than 2 years)
Address:__________________________________________________City:__________________________State:___________________________________ Zip:_________________ Country:___________________

Day Phone:(_____)_____-_______ Evening Phone:(_____)_____-_______ Fax:(_____)_____-_______
Please List 2 Non-Relatives We May Contact For Reference:
Name:_______________________________________Phone: (_____)_____-_______
Name:_______________________________________Phone: (_____)_____-_______
 
Employment (The latest or present employment):
Company name:_______________________________
Supervisors Name:___________________________
Company address:_____________________________________________
Phone number:(______)______-_______
Title of my job:_________________________From:_______________To:________________
Reason for leaving:___________________________________________________________

Have you ever been convicted of a felony?________
If yes, please explain:___________________________________________________________________

 Have you had any experience in advertising?_______
If yes, please describe:__________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________

Have you had any experience with HTML or other programming languages?_______
If yes, please describe:__________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
 
Please tell us about yourself: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
 
Note: I have read and agree to the following:

If accepted as an advertising agent for Advanced Internet Advertising Services, I will conduct business in a professional and honest manner, doing nothing which may hurt the company name in any way. I swear all statements in this application are true and correct and I understand that you may cause an investigative report to be prepared on all information contained herein, and I hereby consent thereto. I understand that if my statements are found to be untrue my agent status will be terminated, and my agent web page will be removed from the Internet.
 
Applicants Signature:___________________________________________ Date:_____/_____/_____