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First Name: *
Middle Name:
Last Name: *
Date of Birth: *
ex. MM-DD-YYYY
SSN: *
ex. XXX-XX-XXXX
Company or DBA:
Tax ID or EIN:
ex. XX-XXXXXXX
Job/Position: *
School Name:
District:
Email: *
Confirm Email: *
Password: *
Confirm Password: *
Cell Phone: *
ex. XXX-XXX-XXXX
Alt Phone:
ex. XXX-XXX-XXXX
Address: *
City: *
State: *
Zip: *
Upline 1 Number: *
Upline 1 Percent: *
 
Upline 2 Number: *
Upline 2 Percent: *
 
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Are you securities licensed? Yes No


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Background Information

Yes   No Yes   No
State: *
License Number: *
 
Texas Temporary Licensee?YesNo
If yes, please explain:

Criminal History


Yes   No
If you answered Yes to any of the above questions, provide city, county, and state of conviction and date and nature of the offense, along with sentencing information. Enter N/A if you answered No and this question does not apply to you.




A conviction will not necessarily be a bar to employment or engagement. This information will only be used for job-related purposes consistent with applicable law and is only relevant in determining whether the conviction is related to the job for which you are applying. Factors such as age at the time of the offense(s), recentness of the offense(s), seriousness of the offense(s), nature of the violation(s), its relation, if any, to the job you are seeking, and rehabilitation will be taken into account. Failure to honestly answer these questions will result in discontinued consideration of your application or termination of employment or engagement.

  • California employees/contractors/residents: You need not disclose any referral to, and participation in, any pre- trial or post-trial diversion program, or any misdemeanor convictions for which probation has been judicially dismissed pursuant to Penal Code Section 1203.4. Do not list any marijuana-related misdemeanor convictions or non-felony convictions for possession of marijuana over two years old, or felony marijuana convictions under California Health and Safety Code Section 11360 (c) which occurred prior to 1976.

California applicants should also read and acknowledge, by initialing, the following statement:

If the Company obtains public records (e.g., records of arrest, conviction, civil rights, tax lien, or outstanding judgment) itself without using a third party, then I am entitled to a copy of such records, unless I check the box. If I am not hired or other adverse action is taken because of the records, then I will receive a copy even if I do check the box.

  • Connecticut employees/contractors/residents: You need not disclose any conviction record that has been erased pursuant to sections 46b-146, 54-76o or 54-142a of the Connecticut General Statutes. Records subject to erasure under these sections are records pertaining to a finding of delinquency or that a child was a member of a family with service needs, an adjudication as a youthful offender, a criminal charge that was dismissed or nolled, or a criminal charge for which the person was found not guilty or received an absolute pardoned conviction. Any person whose records were erased within the meaning of these three sections may consider such events to have never occurred and may so swear under oath.

* Hawaii employees/contractors/residents: You may exclude convictions that occurred over 10 years ago.

* Madison, WI employees/contractors/residents: You may exclude offenses that are more than three years from the date of (i) the placement on probation; (ii) parole; (iii) release from incarceration; (iv) or payment of a fine.

* Massachusetts employees/contractors/residents: An applicant for employment with a sealed record on file with the commissioner of probation may answer “no” to the above with respect to an inquiry herein relative to prior arrests, criminal court appearances or convictions. In addition, any applicant for employment may answer “no” to the above with respect to any inquiry relative to prior arrests, court appearances and adjudications in all cases of delinquency or as a child in need of services which did not result in a complaint transferred to the superior court for criminal prosecution. An applicant for employment with a record expunged pursuant to section 100F, section 100G, section 100H or section 100K of chapter 276 of the General Laws may answer ‘no record’ to an inquiry herein relative to prior arrests, criminal court appearances, juvenile court appearances, adjudications or convictions.

You may exclude information regarding first convictions for the following misdemeanors: drunkenness, simple assault, speeding, minor traffic violations, affray, or disturbance of the peace, or a conviction for any misdemeanor where the conviction occurred or any prison sentence ended three (3) or more years ago whichever date is later, unless you have been convicted of another offense within the last three (3) years.

* Philadelphia, PA employees/contractors/residents: You may exclude convictions that occurred more than 7 years from the date of the inquiry. Any period of incarceration should not be included in the calculation of the 7 year period.

  • San Francisco, CA employees/contractors/residents: You may exclude convictions that occurred over 7 years ago. You also may exclude convictions that arise out of conduct that has been decriminalized since the date of the Conviction, measured from the date of sentencing.
  • Seattle, WA employees/contractors/residents: In addition to the above, you may exclude a criminal conviction that has been the subject of a certificate of rehabilitation or other equivalent procedure based on a finding of the rehabilitation.
  • Washington State employees/contractors/residents: You may exclude convictions that occurred over 10 years ago.

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