Step 1 - The
Application
Please
note that all fields followed by an asterisk must be filled in.
First
Name*
First
Name*
Last
Name*
Last
Name*
E-mail
Address*
E-mail
Address*
Street
Address1*
Street
Address1*
Street
Address2
City*
City*
State/Prov*
State/Prov*
Zip/Postal
Code*
Zip/Postal
Code*
Country*
Country*
Country United States Canada ---------------- Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia
and Herzegovina Botswana Bouvet Island Brazil British
Indian Ocean Territory British
Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central
African Republic Chad Chile China Christmas
Island Cocos Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican
Republic East Timor Ecuador Egypt El Salvador Equatorial
Guinea Eritrea Estonia Ethiopia Falkland
Islands Faroe Islands Fiji Finland France French Guiana French
Polynesia French
Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard
and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kiribadi North Korea South Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall
Islands Martinique Mauritania Mauritius Mayotte Mexico Federated
States of Micronesia Moldova Monaco Mongolia Monserrat Morocco Montenegro Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands
Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern
Mariana Islands Norway Oman Pakistan Palau Panama Papua New
Guinea Paraguay Peru Philippines Pitcairn
Island Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda S.
Georgia and S. Sandwich Isls. Saint
Kitts and Nevis Saint Lucia Saint
Vincent and The Grenadines Samoa San Marino Sao
Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon
Islands Somalia South Africa Spain Sri Lanka St. Helena St.
Pierre and Miquelon Sudan Suriname Svalbard
and Jan Mayen Islands Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad
and Tobago Tunisia Turkey Turkmenistan Turks
and Caicos Islands Tuvalu U.S.
Minor Outlying Islands Uganda Ukraine United
Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam US VIrgin
Islands Wallis
and Futuna Islands Western Sahara Yemen Yugoslavia
(former) Zaire Zambia Zimbabwe
Contact
Phone*
Contact
Phone*
Job
Title*
Job
Title*
Company/Employer
Name*
Company/Employer
Name*
Employer
Address1*
Employer
Address1*
Employer
Address2
Employer
City*
Employer
City*
Employer
State/Prov*
Employer
State/Prov*
Employer
Zip/Postal Code*
Employer
Zip/Postal Code*
Name
of 1st Reference*
Name
of 1st Reference*
1st
Ref E-mail Address*
1st Ref E-mail Address*
Name
of 2nd Reference*
Name
of 2nd Reference*
2nd
Ref E-mail Address*
2nd
Ref E-mail Address*
Name
of 3rd Reference*
Name
of 3rd Reference*
3rd
Ref E-mail Address*
3rd
Ref E-mail Address*
Representation and
Agreement
Applicant
represents that by clicking on the "Submit Application" button below in
conjunction with remittance of the appropriate membership fee
and submission of additional required documentation, that applicant is
applying for membership in the International Professional Alliance of
Staffing Specialists (iPASS) and consents that the performance of the
above described actions constitute
applicant's voluntary creation of an electronic signature that shall be
as valid as an original "wet" signature.
Authorization
Applicant
hereby authorizes any investigator or duly appointed
representative of iPASS bearing this release to obtain any
information from my current and previous employers, clients, schools,
trainers/training programs, and/or references as it relates to my
professional recruiting development, experience, and the performance
thereof.
This information may include, but is not limited to, academic,
achievement, performance, attendance, personal history,
disciplinary, and employment records. I hereby direct you to
release such information upon request of the bearer. I understand that
the information released is for official use by iPASS in determining
whether or not to approve my request for recruiter certification and
may be
disclosed to such third parties as necessary in the credentialing
process.
I hereby release any individual, including record custodians, from any
and all liability for damages of whatever kind or nature which may at
any time result to me on account of compliance, or any attempts to
comply, with this authorization. This authorization for investigation
shall expire 90
days from the date provided. This authorization and consent shall be
valid in original, fax, electronic, or copy form.
Please enter the word that you see below.
