Request Reference Number

* Required Field

*First Name: Middle Initial: *Last Name:

Date of Birth:

*Month: *Day: *Year: (Used to verify your identity and make sure unauthorized updates are not made to your file.)

Address:

City: State: Zip:

*E-Mail Address:

Please be sure to enter all phone numbers in the following format: 7132282200.

Home Phone: Work Phone: Extension:

Cell Phone: Alternate:

RGIS Employment Info

*What is your current employment status with RGIS?
(If you still work for RGIS select "Current Employee" otherwise select "Former Employee")

Did you ever work more than 40 hours in one week for RGIS?

What Position(s) did you work? (Answer Yes To All That Apply. A blank response = "No")

Auditor:

Assistant Team Leader:

Team Leader:

Associate Area Manager:

What is the last RGIS district you worked for? (If you don't remember select "Do Not Recall")