Full Name: *   Address: *   City: *   State: *   Zip: *   Phone: *   Email: *

Have you ever worked for BRG Research Services?* Yes No   If yes, Please provide information as to why stopped working                       How did you hear about BRG?   If referred, by whom?                     BRG Research Services conducts its operations at set schedules, we are currently hiring only those applicants who are able to work during these specific times. In order to be eligible for a "work from home" position you must be able to work one of the following schedules. Please select which schedule you are applying to be on. You must be able to work at least 6 days a week, Monday through Friday and Saturday or Sunday. We currently only have part-time positions available, up to 29 hours per week Monday - Friday 7:00am - 2:45pm MST (Dayshift) Monday - Friday 3:00pm - 9:30pm MST (Nightshift) Saturday 11:00am - 7:00pm MST (Dayshift) Sunday 11:00am - 7:00pm MST (Dayshift) BRG Research Services is committed to assuring that there will always be work available for you as an Interviewer when you are scheduled to work.  However, due to the nature of the business we are in, there may be days when you will not be able to work your scheduled shift due to a lack of work.  We promise to do all we can to avoid this situation but also concede that this may occur due to circumstances which are often out of our control.

	Do you have a noise free work area to perform your job in? * Yes No
	Are you capable of sitting at a computer for long periods of time?* Yes No Please Explain*:
	Do you have any household pets?* Yes No Please Explain*:
	Are there additional members in your household?* Yes No Please Explain:*:

	Are you a citizen of the United States or do you have a right to be legally employed in the US?* Yes No
	If not a citizen of the United States, can you provide proof that you can legally be employed in the US?* Yes No
	Have you ever been convicted of a felony?* Yes No   If yes, please explain:

		Institution Name	Location
Diploma/Degree
Major
	High Sch:
	College:
	Graduate:
	Other:

	Have you ever had experience in research? Yes No
	Have you ever had experience in data entry or coding? Yes No
	Typing Speed 10-Key Speed
	List any other skills you think will help us in determining your qualifications
	Other than English, are there any other languages you can speak fluently? Yes No   If yes, please list:
	Do you own a 4-port Router? Yes No   If yes, Please list the Brand and Model Number:
	Do you currently have High Speed Internet? Yes No   If yes, Please list the Provider and Upload/Download Speed
	Explain why BRG Research Services should hire you to be a stay at home Research Agent: (Be as specific as possible, including all skills, language skills, past experience and current certifications you may hold)

	Most Recent or Current Employer	Address & Phone
	Date Started:	Name of Supervisor / Title
	Date Ended:
	Starting Wages:	Reason For Leaving:
	Ending Wages:
	Explanation of Your Position
	Previous Employer	Address & Phone
	Date Started:	Name of Supervisor / Title
	Date Ended:
	Starting Wages:	Reason For Leaving:
	Ending Wages:
	Explanation of Your Position

	Provide two references, preferably former, or current employer(s). If not an employer please provide two references that are of no relation to you:
	Name:		Name:
	Employer:		Employer:
	Relationship:		Relationship:

	I certify that all information provided by me herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand that this application does not constitute and is not intended to be a contract of employment. IN the event of employment, I understand that false or misleading information, or omission of, given in my application or interview(s) may result in discharge. I understand, that I will be required to abide by all the rules, regulations, policies and procedures of BRG Research Services.
	Initials:*

BRG Research Services, Inc. is an Equal Opportunity Employer. Applicants are considered for all positions without regard to political affiliation, religion, gender, race, color, national origin, sexual orientation, ability, marital or veteran status, the presence of an on-job-related medical condition or handicap, or other status protected under local, state or federal laws.