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Professional Profile
The Regent Group
Important: We ask that you review this document and the information requested. We also suggest that you have all of the necessary informationavailable prior to commencement. It is important to know that this document can not be saved mid way through and reopened later. You must completethe document in its entirety prior to submitting. You are not obligated to answer any questions to which you would have personal objections.
We also ask that we not use phrases such as "See Resume". If there is an item on your resume that you feel is appropriate to include inthis document, please copy & paste it into the content of the profile.
Confidentiality: The information contained herein will be held confidential. The Regent Group (TRG) will only share profile information with thosecompanies that we have secured a job order where your background is a potential fit and you have agreed to pursue the employment opportunity. Inaddition, we will not contact your current employer for a reference check, unless you instruct us to do so. If you should accept a position with one of ourclient companies, you should be aware that they often times require a referencce to be completed once your new employment begins.
General Information
First Name
Last Name
M.I.
Date
Street Address
City
State
Zip Code
Home Phone
Personal E-mail
Business Phone
Business E-mail
Cellular Phone
Other E-mail
Social Security #
Emergency Contact Name & Phone
Are you a citizen of the United States?
If no, are you authorized to work in the U.S.?
Have you ever been convictedof a felony?
If yes, explain:
Have you applied with other recruiting firms orcompanies direct over the past year?
If so, who?
Willing to relocate?
Preferred
Locations
Locations you would not consider:
If required by The Regent Group or our client companies, will you allow the following:
Verification of Compensation
(W-2, 1099 or pay stub?)
Reference
Check?
Credit
Check?
Background
Check?
Education
Check?
*a conviction record will not necessarily bar applicants from hire

Previous Employment - Please do not substitute resume.
Company Name:
Type of Company :
Company Address:
Phone Number :
Job Title:
Starting Salary:
Ending Salary:
Responsibilities:
Promotions Received:
Dates of Employment:
From:
To:
Reason forLeaving:
May we contact your previous supervisor for a reference?
Supervisors Name/Title:
Company Name:
Type of Company :
Company Address:
Phone Number :
Job Title:
Starting Salary:
Ending Salary:
Responsibilities:
Promotions Received:
Dates of Employment:
From:
To:
Reason forLeaving:
May we contact your previous supervisor for a reference?
Supervisors Name/Title:
Company Name:
Type of Company :
Company Address:
Phone Number :
Job Title:
Starting Salary:
Ending Salary:
Responsibilities:
Promotions Received:
Dates of Employment:
From:
To:
Reason forLeaving:
May we contact your previous supervisor for a reference?
Supervisors Name/Title:
Compensation
In order to ensure we understand your total current or most recent compensation plan, please list the following:
Base Salary:
Commissions:
Bonuses?
What has been your average bonus?
401K or other investment matching programs?
Pending Raises & when expected?
Stock Options/Grants?
Profit Sharing?
Cars?
Car Allowance?
Amount?
Tuition Reimbursement?
Compensation Days for unpaid business travel time?
Deferred Compensation?
Vacation?
Personal Days?
Paid Sick Leave?
County ClubMembership?
Health Club
Membership?
Medical Insurance% Employer Paid
Vision Insurance% Employer Paid
Life Insurance %Employer Paid
Dental Insurance% Employer Paid
Position Applied for:
Desired Salary:
What is your total cash compensation expectation for your next position?
Additional work experience, languagesspoken, interests and/or comments to be noted:
Additional Items for Consideration?
Education/Designations/Licenses
High School
Address
Dates Attended:
From:
To:
Did you graduate?
Degree:
Under
Graduate
Address
Dates Attended:
From:
To:
Did you graduate?
Degree:
College
Address
Dates Attended:
From:
To:
Did you graduate?
Degree:
Advanced
Degree
Address
Dates Attended:
From:
To:
Did you graduate?
Degree:
Designations
/Licenses
Address
Dates Attended:
From:
To:
Did you graduate?
Degree:
Designations
/Licenses
Address
Dates Attended:
From:
To:
Did you graduate?
Degree:
Please list three professional references. Direct Supervisor Preferred
TRG reserves the right to contact the references you provide. Information gathered will be held confidential. TRG will only share reference informationwith those companies that have a job opening where your background is a potential fit and you have agreed to pursue the employment opportunity.
Full Name:
Title/Relationship:
Company:
Type of Company:
Phone Number:
E-mail address:
Full Name:
Title/Relationship:
Company:
Type of Company:
Phone Number:
E-mail address:
Full Name:
Title/Relationship:
Company:
Type of Company:
Phone Number:
E-mail address:
List any Companies that you haveinterviewed with in the last six (6) months:
List any Companies that you haveinterviewed with in the last six (6) months:
1. 4.
2. 5.
3.
Name 5 Competitors:
1. 4.
2. 5.
3.
Disclaimer and Signature
I certify that the information provided in this application is accurate to the best of my knowledge and belief. I understand thatmisrepresentation or omission of facts called for on this form may result in refusal of presentation for employment. I authorizeThe Regent Group® to investigate all statements contained in this form, if necessary to determine complete qualification.
If this application leads to employment, I understand that false or misleading information in my application or interview may resultin my release.
By signing below you also agree that if required or requested by The Regent Group or their client you will provide proof oflicensing, certification, degrees or W-2's.
Typed Signature:
Electronic Signature Formatting - //John Smith//
Date:
Siena Office Park Center II 2850 Horizon Ridge Pkwy., Suite 200 Henderson, Nevada 89052 Phone 702-430-4600 Fax (702) 430-4601www.theregentgroup.com
Copyright 2006 The Regent Group, Inc. All Rights Reserved. An Equal Opportunity Employer.

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