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Candidate Screening Form - Agency Re


*To be completed by the Recruitment Agency for ALL requisitions and su Contact Information Address Job Code

Agency Details Agency Name Tephra Recruiter Name Harsh Jiandani Email harsh@tephrainc.com

Proof Of Eligibility To Work In The United S Does the candidate have permanent eligibility to work in the United States? If no, please answer the following questions. What type of Visa do you currently hold? What is your original entry date in H1 (b) Status? What is the Effective Date of first H1 (b) approval? What is your Visa MAX OUT date? Is there any time you spent outside the US that you reclaim? Are you currently employed in full-time status in a valid working Visa status? Do you have an application for adjustment of status (Green Card) based on employment, pending with the INS? Do you have a priority date? Compensation Details Current Base Salary (Ex. $100,000 Per Annum) Current Bonus Plan (If applicable, state percentage and how it is qualified) Current Benefits (Include stock, pension, 401K etc) Desired Base Salary (Ex. $150,000 Per Annum) Desired Package Candidate Details Latest/Current Employer Why is the candidate considering new opportunities at this time? Education (Include: University, Major Field of Study and Degree Obtained) Willing to relocate? Yes/No Percentage of time willing to travel: (None, 5%, up to 25%, up to 50%, 100%) When is the candidate available to interview in person (in another city)? Notice Period? [How much time does the candidate need to schedule an interview?] When is the candidate available to start another opportunity? Does the candidate have any current offers under considerations? (If yes, please include timeframe and details.) How is the candidate going to make a decision on an opportunity (e.g. if they have multiple offers, what are the top 3 decision criteria)? Has the candidate been in contact with anyone from the Company in reference to employment in the past? (If yes, please state position and recruiter.) Previously employed by this Company? If yes, please provide dates. Previously employed by any of Company's Business Partner? If yes, please provide name and dates. Has the candidate worked with any of the Company's personnel in the past (If yes, please provide name.)

Why is the candidate considering this Company as a potential employer? What type of position or responsibilities is the candidate seeking (what do they want to do)? Candidate Summary (Please include as much detail as possible as to why they are a strong candidate for this specific job and our Company) Non-Compete Does the candidate have a non-compete or other restrictive agreement or other continuing obligations of any kind with their current or former employer? (Note: this includes an agreement regarding confidential information, an agreement regarding the handling/ownership of intellectual property, a noncompete agreement, a non-solicitation of clients or employees agreement, a stock option agreement, a restricted stock agreement, a retention agreement or any other similar agreement)? If yes, please provide details. Government Employment Is the candidate currently, or ever been employed by the Federal Government, as either a civilian employee or as a member of the military? If yes, please answer the following questions. Dates of employment? While with the Federal Government or military, did the candidate have any responsibilities or involvement with activities related to this Company or any affiliated Company? If the candidate is currently engaged with any matter involving this Company or any affiliated Company have they filed a written disqualification from that matter? Has the candidate sought the advice of their government ethics officer in considering employment with this Company; and if so, what recommendation was made? Hospital/ Healthcare - Medical Candidate Scree What type of medicine do they practice? What specialties are you Board Eligible or Certified in? (Might be more than one) What languages do you speak? Have you had any disciplinary actions against you? What are you looking for in a practice? What is your perception of the ideal practice situation? Is there any specialty of your field that really interests you? What medical school did you attend and what year? What residency are you at and date of completion? Where did you do your fellowship? and what years? When do you see yourself making a final decision on a new practice or have you set a timeline for yourself? What are you and your spouse looking for in a community? How is the candidate going to make a decision on an opportunity? (what are the top 3 decision criteria)? Financial Advisor - Candidate Profile Current/ Last Employer Previous Employer Current Position Title Registration for Series 3? Registration for Series 6? Registration for Series 7? Registration for Series 9? Registration for Series 10?

Registration for Series 24? Registration for Series 63? Registration for Series 65? Registration for Series 66? Registration for Life, Accident and Health? Any Other Registrations? Any U-4 Issues? If Yes to U-4 Issues, Please Explain Gross Production Last 12 Months [$K] Total Assets Under Management [$M] Estimated R.O.A Product Mix - % Stocks % Bonds % Fee Based % Funds % Insurance/ Annuities % Options % of Assets Transferrable Total Client Accounts FINRA CRD Number

eening Form - Agency Recruitment

ency for ALL requisitions and submitted with candidate's resume* Contact Information Contact Details Email What is the best way to contact the candidate? Mobile: Home: Agency Details Phone Number +1-908-248-2264 Date Vacancy was discussed with the candidate:

igibility To Work In The United States

Compensation Details

Candidate Details


Government Employment

thcare - Medical Candidate Screen Form

ncial Advisor - Candidate Profile