Client Code Site Date Time
Applicant Basic Data
Last Name First Name Middle Name
Date of Birth M D Y
Social Security Number - -
Place of Birth:(city) (county) (state/nation)
Driver's License Number State
Expiration Date M D Y
Present Address Apt
City County State Zip
Home Phone Work Number Ext
Authorization and Release
I hereby authorize IQM to score the results of this
Personnel Attitudes Inventory and release the results to the test proctor and my
prospective employer. I recognize that this tool will provide discussion points for the
interview in determining how my likes and dislikes match that with my prospective
employers desired work environment. By signing below, I hereby release and hold harmless
the owners of IQM, and their client, and their
directors, officers, employees, and agents from claims arising out of or in any connection
with disclosures of information as authorized by this release. I am willing that a copy of
this Authorization and Release be accepted with the same authority as the original.
Test Number Applicant's Signature Test Date M D Y
Test Tabulations
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