Application for Independent Representatives

                                                                                                          Date:___________

Name:_______________________________________________________________________

Address:_____________________________________________________________________

DOB:_______________________ Phone:______________________Cell:_________________

Email:________________________________


Work History: (List previous 5 jobs, including present employment)

1. Dates:________________________ Company:____________________________________

Supervisor:_______________________________ Contact Number:______________________

Responsibilities/Skills:__________________________________________________________

Reason for Leaving:_____________________________________________________________

2. Dates:_______________________Company:______________________________________

Supervisor:______________________________Contact Number:________________________

Responsibilities/Skills:___________________________________________________________

Reason for Leaving:_____________________________________________________________

3. Dates:______________________Company:_______________________________________

Supervisor:_____________________________Contact Number:_________________________

Responsibilities/Skills:___________________________________________________________

Reason for Leaving:_____________________________________________________________

4. Dates:_____________________Company:________________________________________

Supervisor:___________________________Contact Number:___________________________

Responsibilities/Skills:___________________________________________________________

Reason for Leaving:_____________________________________________________________

5. Dates:____________________Company:_________________________________________

Supervisor:___________________________Contact Number:___________________________

Responsibilities/Skills:__________________________________________________________

Reason for Leaving:_____________________________________________________________

Are there any supervisors you do not wish contacted?_____ Why?_______________________

Education:

High School/Year Completed:_____________________________________________________

College/Technical/Year Completed:_________________________________________________

Degree(s) held:__________________________________________________________________

Have you ever been convicted of a felony/misdemeanor or any other charges other than minor
traffic violations?_______ If so, explain:_______________________________________________

_______________________________________________________________________________

Personal References

1. Name:_______________________________________Phone:__________________________

Address:_______________________________________Email:___________________________

Relationship:____________________________________________________________________

2. Name:______________________________________Phone:___________________________

Address:______________________________________Email:____________________________

Relationship:____________________________________________________________________

3. Name:_____________________________________Phone:_____________________________

Address:_____________________________________Email:______________________________

Relationship:_____________________________________________________________________

Professional References

1. Name:____________________________________Phone:______________________________

Address:____________________________________Email:_______________________________

Relationship:_____________________________________________________________________

2. Name:___________________________________Phone:_______________________________

Address:___________________________________Email:________________________________

Relationship:_____________________________________________________________________

3. Name:__________________________________Phone:________________________________

Address:__________________________________Email:_________________________________

Relationship:_____________________________________________________________________

Why do you want this position?______________________________________________________

________________________________________________________________________________.

What do you believe you can bring to this position?______________________________________

________________________________________________________________________________.

By signing below, you agree that the above statements are true and accurate. You understand that
your representative agreement with Adventure USA, LLC is as an Independent Contractor. All monies will
be paid on commission only and you will be responsible for your own taxes and insurance. Adventure USA,
LLC accepts no responsibility for actions, statements, and claims made by Independent Contractors not in
line with the policies and philosophies of Adventure USA, LLC. You understand that you are responsible to
Adventure USA, LLC to maintain confidentiality in regards to all trade secrets of Advenure USA, LLC.


Signed:__________________________________________________________Dated:___________________