Please complete all sections – front and back.  Type or print.  If any section does not apply, indicate by “N/A”

Name (Last, First, Middle)

Social Security Number

P

E

Present Address (Number, Street, City & State, Zip Code)

Phone Number (include area code

R

S

Permanent address (If Different from above)

Phone Number (include area code)

O

N

Are you a citizen of the U.S. or Do you have the legal right do be employed in the U.S.?

18 or Older

A

Yes

No

L

Have you ever been employed at Pangea? 

If Yes, indicated dates of employment

From

To

Yes

No

M

Branch

Rand or Rating at discharge/retirement

I

L

I

T

(List your military duties that you feel, are related top the position you are seeking)

A

R

Y

E

NAME AND ADDRESS OF SCHOOL

Dates of attendance

Degree or certificate

D

U

C

A

High School

FROM (month/year)

TO (month/year)

YES

NO

Areas of Specialization or type of Degree, If Awarded

T

I

College

O

N

Other

Applicant must be able to obtain and maintain a security clearance to perform duties required.

S

Have you ever been granted a security clearance by any government agency?

If yes, level/clearance

Have you ever terminated employment while a request or application for an access authorization was pending?

E

Yes

No

Yes

No

C

Have you ever been denied a security clearance by any government agency?

If, “yes” indicate when denied and by whom:

U

Yes

No

R

Have you ever been convicted of a felon? (Federal, local or military)

If, “yes” give date, place, charge & disposition:

I

Yes

No

T

Rehabilitation activities engaged in if convicted for a felon?

If, “yes” please explain on reverse side under: remarks”*

Y

Yes

No

* A Conviction will not necessarily disqualify applicant form the job applied for

Position applying for

Status

Availability Date

Salary Expected

Part Time

Day

Full Time

Night

How were you referred?

Advertisement

Friend/Employee

Other

How many days have you missed (or been absent) from work during the last two years?

Geographical Preference

Relocation Restrictions

Travel Restriction

Employment Record

Please account for all periods of employment for the last 7 years beginning with your most recent position.  A resume may be attached to supplement information.

Name or present or last employer

Address

Telephone

From (Mo/Yr)

To (Mo/Yr)

Immediate Supervisor

Reason for leaving

Starting Salary

Final Salary

Job Classification and Duties

Next Previous Employer

Address

Telephone

From (Mo/Yr)

To (Mo/Yr)

Immediate Supervisor

Reason for leaving

Starting Salary

Final Salary

Job Classification and Duties

Next Previous Employer

Address

Telephone

From (Mo/Yr)

To (Mo/Yr)

Immediate Supervisor

Reason for leaving

Starting Salary

Final Salary

Job Classification and Duties

Remarks

Statement below must be signed

I understand that any omission or misrepresentation of material fact in this application may result in refusal of or separation from employment.  I hereby authorize PANGEA, Inc. to make any reference check of my academic credential and employment, I understand that I will be required to sign an Agreement relating to the assignment of inventions of the Company.

All new employees are subject to satisfactory completion of an orientation period of 90 days as a condition of continued employment.  Terms and conditions of employment are subject to the discretion of PANGEA, Inc. and are not based upon any expressed or implied contract.

PANGEA’s EEO objective is to obtain qualified employees consistent with position requirements; to seek, employ, promote, and treat all employees and applicants for employment without discrimination as to race, color, religion, sex national origin, marital status, disability or veteran status.

I agree to abide by and conform to the rules and regulations of the company.

Signature

Date