OUTSIDE INSTRUCTOR FILE

Full Name

First NameMiddle NameLast Name

Personal Phone Number

Email Address

IF BUSINESS ENTITY Business Name

Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Business Phone Number

Experience

Classes/Curriculums you Plan on Teaching

Please list 2 Non Family Member References with Phone Numbers

Why do you want to utilize our facility?

AWARDS, HONORS AND DISTINCTIONS,LAW ENFORCEMENT, MILITARY HISTORY

BACKGROUND INFORMATION

Have you ever been found guilty, accepted a guilty or Alford Plea, or entered a plea of no-contest for any criminal charge? DO NOT INCLUDE TRAFFIC CITATIONS

YesNo

Have you ever been the subject of an investigation into wrongdoing or other formal/informal proceeding, resulting in disciplinary or criminal action?

YesNo

If you answered “yes” to any of the above questions, provide date, incident, specific charge, city/state in which occurred:

Responding "yes" to any of the previous questions is not an automatic bar. The date of the offense and the relationship between the offense or infraction and the position for which you are applying will be considered.

Instructor Certificates

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PLEASE Add the following entities as Additional Insured

Embassy Security Group Inc

19614 S. La Grange Road, Mokena, IL 60448

Empress Protection Training Inc.

DBA Protection Training Academy

19614 S. La Grange Road, Mokena, IL 60448

Certificate of Insurance

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AGREEMENT (Read carefully before signing or submitting electronically) By my signature: • I acknowledge that if I provide false, inaccurate, or incomplete information in the form, or any other communication i understand any and all access to premise may be revoked.. • I acknowledge that to the fullest extent permitted by state and federal law, the Embassy Security Group, Empress Protection Training Inc DBA Protection Training Academy may vet all information concerning my file. The term "all information" includes information of any kind (verbal, written, photographic, videographic, etc.) that is accessible in any medium (print, electronic, etc.) from any source. • If there is information that pertains to me that I believe requires explanation, interpretation, or clarification, it is my obligation to communicate this information. • I authorize Embassy Security Group, Empress Protection Training Inc DBA Protection Training Academy to conduct a check regarding my background including, but not limited to, criminal record, child and dependent adult abuse registry screening, and sex offender registry. I waive any right I may have against any person contacted as a reference concerning this application.

• I understand that this file will be considered active for twelve (12) months from the date filed. • I understand that this form is not a contract of employment.

I understand that I may NOT use Embassy Security Group, Empress Protection Training Inc DBA Protection Training Academy Logos, Media, and other information without Permission.

I fully understand that I will be responsible for obtaining Release Waivers for my students while conducting business, training, or in any way utilizing property of Embassy Security Group, Empress Protection Training Inc DBA Protection Training Academy. I fully understand the risks involved in training activities. I release Embassy Security Group, Empress Protection Training Inc. DBA Protection Training Academy for any liabilities including monatary damages as well as injuries, damages, accidents, thefts or death. I release, waive, hold harmless and indemnify Embassy Security Group, Empress Protection Training Inc. DBA Protection Training Academy including the employees, agents and owners, from any liabilities including monatary damages as well as injuries, damages, accidents, thefts or death. If the Embassy Security Group, Empress Protection Training Inc. DBA Protection Training Academy or it's agents believe that I am involved in any suspicious or criminal activities, I may be removed and barred from the premises.

I confirm that all information I entered in this form is true and accurate.

By my electronic submission of this form: • I attest that all the information contained in this application is accurate, complete, and true. • I am bound by all elements of the agreement section of the application. • I understand and accept that electronic submission will be considered equivalent to an original hand written signature on a paper copy of the application.

Name

Signature

Date