app.epmsonline.com
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199.200.102.179
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URL:
https://app.epmsonline.com/app/shopper/application/
Submission Tags: falconsandbox
Submission: On September 29 via api from US — Scanned from DE
Submission Tags: falconsandbox
Submission: On September 29 via api from US — Scanned from DE
Form analysis 1 forms found in the DOM
POST
<form class="x-panel-body x-form x-column-layout-ct" method="POST" id="ext-gen11" style="padding: 5px 5px 0px; width: 768px;">
<div class="x-column-inner" id="ext-gen23" style="width: 768px;">
<div id="ext-comp-1004" class=" x-panel x-form-label-left x-column" style="width: 460px;">
<div class="x-panel-bwrap" id="ext-gen25">
<div class="x-panel-body x-panel-body-noheader x-panel-body-noborder" id="ext-gen26" style="width: 460px;">
<div class="x-form-item " tabindex="-1" id="ext-gen46"><label for="ext-comp-1007" style="width:160px;" class="x-form-item-label" id="ext-gen47">Name (First/Last):</label>
<div class="x-form-element" id="x-form-el-ext-comp-1005" style="padding-left:165px">
<div id="ext-comp-1006" class=" x-form-composite x-box-layout-ct x-form-field" style="width: 249px;">
<div class="x-box-inner" id="ext-gen49" style="width: 249px; height: 22px;"><input type="text" size="20" autocomplete="off" id="ext-comp-1007" name="firstname" class=" x-form-text x-form-field x-box-item"
style="width: 90px; height: 18px; left: 0px; top: 0px;"><input type="text" size="20" autocomplete="off" id="ext-comp-1008" name="lastname" class=" x-form-text x-form-field x-box-item"
style="width: 138px; height: 18px; left: 103px; top: 0px;"></div>
</div>
</div>
<div class="x-form-clear-left"></div>
</div>
<div class="x-form-item " tabindex="-1" id="ext-gen50"><label for="ext-comp-1009" style="width:160px;" class="x-form-item-label" id="ext-gen51">Street (Mailing) Address:</label>
<div class="x-form-element" id="x-form-el-ext-comp-1009" style="padding-left:165px"><input type="text" size="20" autocomplete="off" id="ext-comp-1009" name="address" class=" x-form-text x-form-field" style="width: 241px;"></div>
<div class="x-form-clear-left"></div>
</div>
<div class="x-form-item " tabindex="-1" id="ext-gen52"><label for="ext-comp-1012" style="width:160px;" class="x-form-item-label" id="ext-gen53">City, State/Province, Zip:</label>
<div class="x-form-element" id="x-form-el-ext-comp-1010" style="padding-left:165px">
<div id="ext-comp-1011" class=" x-form-composite x-box-layout-ct x-form-field" style="width: 249px;">
<div class="x-box-inner" id="ext-gen55" style="width: 249px; height: 22px;"><input type="text" size="20" autocomplete="off" id="ext-comp-1012" name="city" class=" x-form-text x-form-field x-box-item"
style="width: 112px; height: 18px; left: 0px; top: 0px;">
<div class="x-form-field-wrap x-form-field-trigger-wrap x-box-item" id="ext-gen56" style="width: 59px; left: 125px; top: 0px;"><input type="text" size="24" autocomplete="off" id="ext-comp-1003" name="state"
class="x-form-text x-form-field" style="width: 34px;"><img src="data:image/gif;base64,R0lGODlhAQABAID/AMDAwAAAACH5BAEAAAAALAAAAAABAAEAAAICRAEAOw==" alt="" class="x-form-trigger x-form-arrow-trigger" id="ext-gen57"></div><input
type="text" size="20" autocomplete="off" id="ext-comp-1013" name="zip" class=" x-form-text x-form-field x-box-item" style="width: 52px; left: 189px; top: 0px;">
</div>
</div>
</div>
<div class="x-form-clear-left"></div>
</div><label id="ext-comp-1014" class=" application-info" style="width: 414px;">All Nevada shops are contracted through a private investigative firm.</label>
<div class="x-form-item " tabindex="-1" id="ext-gen58"><label for="ext-comp-1015" style="width:160px;" class="x-form-item-label" id="ext-gen59">Date of Birth:</label>
<div class="x-form-element" id="x-form-el-ext-comp-1015" style="padding-left:165px">
<div class="x-form-field-wrap x-form-field-trigger-wrap" id="ext-gen60" style="width: 249px;"><input type="text" size="10" autocomplete="off" id="ext-comp-1015" name="dob" class="x-form-text x-form-field" style="width: 241px;"><img
src="data:image/gif;base64,R0lGODlhAQABAID/AMDAwAAAACH5BAEAAAAALAAAAAABAAEAAAICRAEAOw==" alt="" class="x-form-trigger x-form-date-trigger" id="ext-gen61" style="display: none;"></div>
</div>
<div class="x-form-clear-left"></div>
</div><label id="ext-comp-1016" class=" application-info" style="width: 414px;">You must be at least 18 years of age.</label>
<div class="x-form-item " tabindex="-1" id="ext-gen62"><label for="ext-comp-1017" style="width:160px;" class="x-form-item-label" id="ext-gen63">How did you hear about us?:</label>
<div class="x-form-element" id="x-form-el-ext-comp-1017" style="padding-left:165px">
<div class="x-form-field-wrap x-form-field-trigger-wrap" id="ext-gen64" style="width: 249px;"><input type="text" size="24" autocomplete="off" id="ext-comp-1017" name="lead" class="x-form-text x-form-field" style="width: 224px;"><img
src="data:image/gif;base64,R0lGODlhAQABAID/AMDAwAAAACH5BAEAAAAALAAAAAABAAEAAAICRAEAOw==" alt="" class="x-form-trigger x-form-arrow-trigger" id="ext-gen65"></div>
</div>
<div class="x-form-clear-left"></div>
</div>
<div class="x-form-item x-hide-display" tabindex="-1" id="ext-gen66"><label for="ext-comp-1018" style="width:160px;" class="x-form-item-label" id="ext-gen67">For "Other", how did you hear about us?:</label>
<div class="x-form-element" id="x-form-el-ext-comp-1018" style="padding-left:165px"><textarea style="width: 241px; height: 94px;" autocomplete="off" id="ext-comp-1018" name="lead_other"
class=" x-form-textarea x-form-field x-hide-display"></textarea></div>
<div class="x-form-clear-left"></div>
</div>
<div class="x-form-item " tabindex="-1" id="ext-gen68"><label for="ext-comp-1019" style="width:160px;" class="x-form-item-label" id="ext-gen69">Social Security Number (SSN):</label>
<div class="x-form-element" id="x-form-el-ext-comp-1019" style="padding-left:165px"><input type="text" size="20" autocomplete="off" id="ext-comp-1019" name="socialsecurity" class=" x-form-text x-form-field" style="width: 241px;"></div>
<div class="x-form-clear-left"></div>
</div><label id="ext-comp-1020" class=" application-info" style="width: 414px;">Ellis will not accept an EIN in place of a Social Security Number (SSN). Do NOT enter a SSN other than your true and valid SSN; identity theft is a crime. This
number is used for payroll purposes and will be reported to the IRS. If you enter an EIN or an invalid Social Security Number, you will be inactivated from the Ellis shopper database.</label><label id="ext-comp-1021"
class=" application-info" style="width: 414px;">Under penalties of perjury, I certify that: 1. the Social Security Number (SSN) shown on this form is my correct taxpayer identification number, and 2. I am not subject to backup withholding
because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS
has notified me that I am no longer subject to backup withholding, and 3. I am a U.S. person (including a U.S. resident alien). (Note: Canadian persons are not subject to item 3. regarding U.S. legal residence.)</label>
</div>
</div>
</div>
<div id="ext-comp-1022" class=" x-panel x-form-label-left x-column" style="width: 307px;">
<div class="x-panel-bwrap" id="ext-gen28">
<div class="x-panel-body x-panel-body-noheader x-panel-body-noborder" id="ext-gen29" style="width: 307px;">
<fieldset id="ext-comp-1023" class=" x-fieldset x-form-label-left" style="width: 285px;">
<legend class="x-fieldset-header x-unselectable" id="ext-gen70"><span class="x-fieldset-header-text" id="ext-gen73">Email</span></legend>
<div class="x-fieldset-bwrap" id="ext-gen71">
<div class="x-fieldset-body" id="ext-gen72" style="width: 285px;">
<div class="x-form-item " tabindex="-1" id="ext-gen85"><label for="ext-comp-1024" style="width:100px;" class="x-form-item-label" id="ext-gen86">Primary:</label>
<div class="x-form-element" id="x-form-el-ext-comp-1024" style="padding-left:105px"><input type="text" size="20" autocomplete="off" id="ext-comp-1024" name="email" class=" x-form-text x-form-field" style="width: 143px;"></div>
<div class="x-form-clear-left"></div>
</div>
<div class="x-form-item " tabindex="-1" id="ext-gen87"><label for="ext-comp-1025" style="width:100px;" class="x-form-item-label" id="ext-gen88">Alternate:</label>
<div class="x-form-element" id="x-form-el-ext-comp-1025" style="padding-left:105px"><input type="text" size="20" autocomplete="off" id="ext-comp-1025" name="alt_email" class=" x-form-text x-form-field" style="width: 143px;"></div>
<div class="x-form-clear-left"></div>
</div>
</div>
</div>
</fieldset>
<fieldset id="ext-comp-1026" class=" x-fieldset x-form-label-left" style="width: 285px;">
<legend class="x-fieldset-header x-unselectable" id="ext-gen75"><span class="x-fieldset-header-text" id="ext-gen78">Phone</span></legend>
<div class="x-fieldset-bwrap" id="ext-gen76">
<div class="x-fieldset-body" id="ext-gen77" style="width: 285px;"><label id="ext-comp-1027" class=" application-info">Check the box to the right if we can text you at this number.</label>
<div class="x-form-item " tabindex="-1" id="ext-gen89"><label for="ext-comp-1030" style="width:100px;" class="x-form-item-label" id="ext-gen90">Primary:</label>
<div class="x-form-element" id="x-form-el-ext-comp-1028" style="padding-left:105px">
<div id="ext-comp-1029" class=" x-form-composite x-box-layout-ct x-form-field" style="width: 180px;">
<div class="x-box-inner" id="ext-gen92" style="width: 180px; height: 36px;"><input type="text" size="20" autocomplete="off" id="ext-comp-1030" name="phoneno" class=" x-form-text x-form-field x-box-item"
style="width: 147px; height: 18px; left: 0px; top: 0px;">
<div class="x-form-check-wrap x-box-item" id="ext-gen93" style="left: 160px; top: 0px;"><input type="hidden" id="ext-gen95" value="0" name="phoneno_sms"><input type="checkbox" autocomplete="off" id="ext-comp-1031"
name="phoneno_sms" class=" x-form-checkbox x-form-field" value="1"><label for="ext-comp-1031" class="x-form-cb-label" id="ext-gen94"> </label></div>
</div>
</div>
</div>
<div class="x-form-clear-left"></div>
</div>
<div class="x-form-item " tabindex="-1" id="ext-gen96"><label for="ext-comp-1034" style="width:100px;" class="x-form-item-label" id="ext-gen97">Alternate:</label>
<div class="x-form-element" id="x-form-el-ext-comp-1032" style="padding-left:105px">
<div id="ext-comp-1033" class=" x-form-composite x-box-layout-ct x-form-field" style="width: 180px;">
<div class="x-box-inner" id="ext-gen99" style="width: 180px; height: 36px;"><input type="text" size="20" autocomplete="off" id="ext-comp-1034" name="alt_phone" class=" x-form-text x-form-field x-box-item"
style="width: 147px; height: 18px; left: 0px; top: 0px;">
<div class="x-form-check-wrap x-box-item" id="ext-gen100" style="left: 160px; top: 0px;"><input type="hidden" id="ext-gen102" value="0" name="alt_phone_sms"><input type="checkbox" autocomplete="off" id="ext-comp-1035"
name="alt_phone_sms" class=" x-form-checkbox x-form-field" value="1"><label for="ext-comp-1035" class="x-form-cb-label" id="ext-gen101"> </label></div>
</div>
</div>
</div>
<div class="x-form-clear-left"></div>
</div>
</div>
</div>
</fieldset>
<fieldset id="ext-comp-1036" class=" x-fieldset x-form-label-left" style="width: 285px;">
<legend class="x-fieldset-header x-unselectable" id="ext-gen80"><span class="x-fieldset-header-text" id="ext-gen83">Password Selection</span></legend>
<div class="x-fieldset-bwrap" id="ext-gen81">
<div class="x-fieldset-body" id="ext-gen82" style="width: 285px;">
<div class="x-form-item " tabindex="-1" id="ext-gen103"><label for="password" style="width:100px;" class="x-form-item-label" id="ext-gen104">Password:</label>
<div class="x-form-element" id="x-form-el-password" style="padding-left:105px"><input type="password" size="20" autocomplete="off" id="password" name="password" class=" x-form-text x-form-field" style="width: 143px;"></div>
<div class="x-form-clear-left"></div>
</div>
<div class="x-form-item " tabindex="-1" id="ext-gen105"><label for="password-confirm" style="width:100px;" class="x-form-item-label" id="ext-gen106">Confirm:</label>
<div class="x-form-element" id="x-form-el-password-confirm" style="padding-left:105px"><input type="password" size="20" autocomplete="off" id="password-confirm" name="password-confirm" class=" x-form-text x-form-field"
style="width: 143px;"></div>
<div class="x-form-clear-left"></div>
</div>
</div>
</div>
</fieldset>
</div>
</div>
</div>
<div id="ext-comp-1037" class=" x-panel x-form-label-left x-column" style="width: 384px;">
<div class="x-panel-bwrap" id="ext-gen31">
<div class="x-panel-body x-panel-body-noheader x-panel-body-noborder" id="ext-gen32" style="width: 384px;">
<fieldset id="ext-comp-1038" class=" x-fieldset x-form-label-top" style="width: 354px;">
<legend class="x-fieldset-header x-unselectable" id="ext-gen107"><span class="x-fieldset-header-text" id="ext-gen110">Relations to Management Companies</span></legend>
<div class="x-fieldset-bwrap" id="ext-gen108">
<div class="x-fieldset-body" id="ext-gen109" style="width: 354px;">
<div class="x-form-item x-hide-label" tabindex="-1" id="ext-gen112"><label for="ext-comp-1039" style="width:auto;" class="x-form-item-label" id="ext-gen113"></label>
<div class="x-form-element" id="x-form-el-ext-comp-1039" style="padding-left:0;"><textarea style="width: 338px; height: 60px;" autocomplete="off" id="ext-comp-1039" name="mgmtcosworkedfor"
class=" x-form-textarea x-form-field"></textarea></div>
<div class="x-form-clear-left"></div>
</div><label id="ext-comp-1040" class=" application-info">If you, a close friend, or relative are currently or were previously employed by a property management company within the last 10 years - OR - if you are currently or were
previously a resident at a community owned or managed by a property management company within the last 10 years, you must note the management company's name in the space provided. It is your responsibility to notify Ellis of this
information now, and if encountered after registering as a shopper. Failure to do so could result in your inability to shop for us.</label>
</div>
</div>
</fieldset>
</div>
</div>
</div>
<div id="ext-comp-1041" class=" x-panel x-form-label-left x-column" style="width: 384px;">
<div class="x-panel-bwrap" id="ext-gen34">
<div class="x-panel-body x-panel-body-noheader x-panel-body-noborder" id="ext-gen35" style="width: 384px;">
<fieldset id="ext-comp-1042" class=" x-fieldset x-form-label-top" style="width: 358px;">
<legend class="x-fieldset-header x-unselectable" id="ext-gen114"><span class="x-fieldset-header-text" id="ext-gen117">Mystery Shopping Experience</span></legend>
<div class="x-fieldset-bwrap" id="ext-gen115">
<div class="x-fieldset-body" id="ext-gen116" style="width: 358px;"><label id="ext-comp-1043" class=" application-info">Do you contract with any other Mystery Shopping Companies?</label>
<div class="x-form-item x-hide-label" tabindex="-1" id="ext-gen119"><label for="ext-comp-1044" style="width:auto;" class="x-form-item-label" id="ext-gen120"></label>
<div class="x-form-element" id="x-form-el-ext-comp-1044" style="padding-left:0;">
<div id="ext-comp-1044" class=" x-form-radio-group x-column-layout-ct x-form-field" style="width: 143px;">
<div class="x-column-inner" id="ext-gen122" style="width: 143px;">
<div id="ext-comp-1063" class=" x-column" style="width: 71px;">
<div class="x-form-item x-hide-label" tabindex="-1" id="ext-gen126"><label for="ext-comp-1064" style="width:100px;" class="x-form-item-label" id="ext-gen127"></label>
<div class="x-form-element" id="x-form-el-ext-comp-1064" style="padding-left:105px">
<div class="x-form-check-wrap" id="ext-gen128" style="width: 71px;"><input type="radio" autocomplete="off" id="ext-comp-1064" name="shop_for_other" class=" x-form-radio x-form-field" value="1"><label for="ext-comp-1064"
class="x-form-cb-label" id="ext-gen129">Yes</label></div>
</div>
<div class="x-form-clear-left"></div>
</div>
</div>
<div id="ext-comp-1065" class=" x-column" style="width: 71px;">
<div class="x-form-item x-hide-label" tabindex="-1" id="ext-gen130"><label for="ext-comp-1066" style="width:100px;" class="x-form-item-label" id="ext-gen131"></label>
<div class="x-form-element" id="x-form-el-ext-comp-1066" style="padding-left:105px">
<div class="x-form-check-wrap" id="ext-gen132" style="width: 71px;"><input type="radio" autocomplete="off" id="ext-comp-1066" name="shop_for_other" class=" x-form-radio x-form-field" value="0"><label for="ext-comp-1066"
class="x-form-cb-label" id="ext-gen133">No</label></div>
</div>
<div class="x-form-clear-left"></div>
</div>
</div>
<div class="x-clear" id="ext-gen123"></div>
</div>
</div>
</div>
<div class="x-form-clear-left"></div>
</div>
<div id="ext-comp-1045" class=" x-panel x-form-label-top x-hide-display" style="width: 358px;">
<div class="x-panel-bwrap" id="ext-gen134">
<div class="x-panel-body x-panel-body-noheader x-panel-body-noborder" id="ext-gen135" style="width: 358px;">
<div class="x-form-item x-hide-label" tabindex="-1" id="ext-gen137"><label for="ext-comp-1046" style="width:auto;" class="x-form-item-label" id="ext-gen138"></label>
<div class="x-form-element" id="x-form-el-ext-comp-1046" style="padding-left:0;"><textarea style="width:100px;height:60px;" autocomplete="off" id="ext-comp-1046" name="shop_for_other_list"
class=" x-form-textarea x-form-field"></textarea></div>
<div class="x-form-clear-left"></div>
</div><label id="ext-comp-1047" class=" application-info">Please list all other Mystery Shopping Companies you do work for. One company per line.</label>
</div>
</div>
</div><label id="ext-comp-1048" class=" application-info">Visit the <a href="https://mspa-americas.org/">Mystery Shopping Providers Association</a> (MSPA) website to find other Mystery Shopping Companies.</label>
</div>
</div>
</fieldset>
</div>
</div>
</div>
<div id="ext-comp-1049" class=" x-panel x-form-label-left x-column" style="width: 768px;">
<div class="x-panel-bwrap" id="ext-gen37">
<div class="x-panel-body x-panel-body-noheader x-panel-body-noborder" id="ext-gen38" style="width: 768px;">
<div class="x-form-item x-hide-label" tabindex="-1" id="ext-gen139"><label for="ext-comp-1050" style="width:100px;" class="x-form-item-label" id="ext-gen140"></label>
<div class="x-form-element" id="x-form-el-ext-comp-1050" style="padding-left:105px">
<div class="x-form-check-wrap" id="ext-gen141" style="width: 691px;"><input type="hidden" id="ext-gen143" value="0" name="not_felon_check"><input type="checkbox" autocomplete="off" id="ext-comp-1050" name="not_felon_check"
class=" x-form-checkbox x-form-field" value="1"><label for="ext-comp-1050" class="x-form-cb-label" id="ext-gen142">I have never been charged, detained, or arrested for a felony or sex related crime that was resolved by conviction,
probation, deferred adjudication, court ordered community supervision, or pretrial diversion.</label></div>
</div>
<div class="x-form-clear-left"></div>
</div>
<div class="x-form-item x-hide-label" tabindex="-1" id="ext-gen144"><label for="ext-comp-1051" style="width:100px;" class="x-form-item-label" id="ext-gen145"></label>
<div class="x-form-element" id="x-form-el-ext-comp-1051" style="padding-left:105px">
<div class="x-form-check-wrap" id="ext-gen146" style="width: 691px;"><input type="hidden" id="ext-gen148" value="0" name="agreement"><input type="checkbox" autocomplete="off" id="ext-comp-1051" name="agreement"
class=" x-form-checkbox x-form-field" value="1"><label for="ext-comp-1051" class="x-form-cb-label" id="ext-gen147">I agree to the terms detailed above.</label></div>
</div>
<div class="x-form-clear-left"></div>
</div>
</div>
</div>
</div>
<div id="ext-comp-1052" class=" x-panel x-form-label-left x-column" style="width: 768px;">
<div class="x-panel-bwrap" id="ext-gen40">
<div class="x-panel-body x-panel-body-noheader x-panel-body-noborder" id="ext-gen41" style="width: 768px;"><label id="ext-comp-1053" class=" application-info"><br>Ellis online offers mystery shopping opportunities to independent freelance
mystery shoppers. To confirm your eligibility to accept a mystery shopping opportunity through Ellis online, please click the boxes below that correspond with statements that are true as applied to you.</label></div>
</div>
</div>
<div id="ext-comp-1054" class=" x-panel x-form-label-left x-column" style="width: 768px;">
<div class="x-panel-bwrap" id="ext-gen43">
<div class="x-panel-body x-panel-body-noheader x-panel-body-noborder" id="ext-gen44" style="width: 768px;">
<div class="x-form-item x-hide-label" tabindex="-1" id="ext-gen149"><label for="ext-comp-1055" style="width:100px;" class="x-form-item-label" id="ext-gen150"></label>
<div class="x-form-element" id="x-form-el-ext-comp-1055" style="padding-left:105px">
<div class="x-form-check-wrap" id="ext-gen151" style="width: 691px;"><input type="hidden" id="ext-gen153" value="0" name="selfemployed1"><input type="checkbox" autocomplete="off" id="ext-comp-1055" name="selfemployed1"
class=" x-form-checkbox x-form-field" value="1"><label for="ext-comp-1055" class="x-form-cb-label" id="ext-gen152">I am a self-employed mystery shopper and I offer my mystery shopping services on a freelance basis.</label></div>
</div>
<div class="x-form-clear-left"></div>
</div>
<div class="x-form-item x-hide-label" tabindex="-1" id="ext-gen154"><label for="ext-comp-1056" style="width:100px;" class="x-form-item-label" id="ext-gen155"></label>
<div class="x-form-element" id="x-form-el-ext-comp-1056" style="padding-left:105px">
<div class="x-form-check-wrap" id="ext-gen156" style="width: 691px;"><input type="hidden" id="ext-gen158" value="0" name="selfemployed2"><input type="checkbox" autocomplete="off" id="ext-comp-1056" name="selfemployed2"
class=" x-form-checkbox x-form-field" value="1"><label for="ext-comp-1056" class="x-form-cb-label" id="ext-gen157">I do not rely solely on Ellis online for obtaining mystery shopping opportunities but also actively obtain such
opportunities through other means.</label></div>
</div>
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<div class="x-form-item x-hide-label" tabindex="-1" id="ext-gen159"><label for="ext-comp-1057" style="width:100px;" class="x-form-item-label" id="ext-gen160"></label>
<div class="x-form-element" id="x-form-el-ext-comp-1057" style="padding-left:105px">
<div class="x-form-check-wrap" id="ext-gen161" style="width: 691px;"><input type="hidden" id="ext-gen163" value="0" name="selfemployed3"><input type="checkbox" autocomplete="off" id="ext-comp-1057" name="selfemployed3"
class=" x-form-checkbox x-form-field" value="1"><label for="ext-comp-1057" class="x-form-cb-label" id="ext-gen162">I understand that Ellis online is merely a source through which I can obtain mystery shopping opportunities and that
when I perform such an opportunity I will work independently and not for Ellis online.</label></div>
</div>
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<div class="x-form-item x-hide-label" tabindex="-1" id="ext-gen164"><label for="ext-comp-1058" style="width:100px;" class="x-form-item-label" id="ext-gen165"></label>
<div class="x-form-element" id="x-form-el-ext-comp-1058" style="padding-left:105px">
<div class="x-form-check-wrap" id="ext-gen166" style="width: 691px;"><input type="hidden" id="ext-gen168" value="0" name="selfemployed4"><input type="checkbox" autocomplete="off" id="ext-comp-1058" name="selfemployed4"
class=" x-form-checkbox x-form-field" value="1"><label for="ext-comp-1058" class="x-form-cb-label" id="ext-gen167">I understand that the reason Ellis online requests my responses to the foregoing questions is to ensure that it only
does business with mystery shoppers who truly are self-employed, and I hereby represent and affirm that I checked only those boxes that are true and correct as applied to me and hereby waive any right to dispute the correctness of
any statement corresponding to a box that I checked.</label></div>
</div>
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<div class="x-clear" id="ext-gen24"></div>
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</form>Text Content
SHOPPER APPLICATION Name (First/Last): Street (Mailing) Address: City, State/Province, Zip: All Nevada shops are contracted through a private investigative firm. Date of Birth: You must be at least 18 years of age. How did you hear about us?: For "Other", how did you hear about us?: Social Security Number (SSN): Ellis will not accept an EIN in place of a Social Security Number (SSN). Do NOT enter a SSN other than your true and valid SSN; identity theft is a crime. This number is used for payroll purposes and will be reported to the IRS. If you enter an EIN or an invalid Social Security Number, you will be inactivated from the Ellis shopper database.Under penalties of perjury, I certify that: 1. the Social Security Number (SSN) shown on this form is my correct taxpayer identification number, and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. I am a U.S. person (including a U.S. resident alien). (Note: Canadian persons are not subject to item 3. regarding U.S. legal residence.) Email Primary: Alternate: Phone Check the box to the right if we can text you at this number. Primary: Alternate: Password Selection Password: Confirm: Relations to Management Companies If you, a close friend, or relative are currently or were previously employed by a property management company within the last 10 years - OR - if you are currently or were previously a resident at a community owned or managed by a property management company within the last 10 years, you must note the management company's name in the space provided. It is your responsibility to notify Ellis of this information now, and if encountered after registering as a shopper. Failure to do so could result in your inability to shop for us. Mystery Shopping Experience Do you contract with any other Mystery Shopping Companies? Yes No Please list all other Mystery Shopping Companies you do work for. One company per line. Visit the Mystery Shopping Providers Association (MSPA) website to find other Mystery Shopping Companies. I have never been charged, detained, or arrested for a felony or sex related crime that was resolved by conviction, probation, deferred adjudication, court ordered community supervision, or pretrial diversion. I agree to the terms detailed above. Ellis online offers mystery shopping opportunities to independent freelance mystery shoppers. To confirm your eligibility to accept a mystery shopping opportunity through Ellis online, please click the boxes below that correspond with statements that are true as applied to you. I am a self-employed mystery shopper and I offer my mystery shopping services on a freelance basis. I do not rely solely on Ellis online for obtaining mystery shopping opportunities but also actively obtain such opportunities through other means. I understand that Ellis online is merely a source through which I can obtain mystery shopping opportunities and that when I perform such an opportunity I will work independently and not for Ellis online. I understand that the reason Ellis online requests my responses to the foregoing questions is to ensure that it only does business with mystery shoppers who truly are self-employed, and I hereby represent and affirm that I checked only those boxes that are true and correct as applied to me and hereby waive any right to dispute the correctness of any statement corresponding to a box that I checked. Save Cancel