Personal Information

				Date:
Name:
Present Address:
City:			How Long?		years
State:
Zip:			Position Applied For?	Please select requested position Financial Advisors Registered Representatives Sales Assistant Assistant Editor/Research Assistant Bookkeeper
Email:			Desired Salary?
Phone:
			Employment desired	Full-Time Part-Time Other
			Total hours available	Please Choose 10-15 hours 15-20 hours 20-25 hours 25-30 hours 40+ hours
			Can you work nights?	yes no
			When can you start?

Education Information

High School Attended				Did you graduate?	- Yes No	Year
College Attended				Did you graduate?	- Yes No	Year
Bus. or Trade School				Did you graduate?	- Yes No	Year
Professional School				Did you graduate?	- Yes No	Year
Have you ever been convicted of a crime?
Please choose No Yes
If yes, please explain
Do you have a drivers license?		Yes No
Drivers License #
State of Issue:
Expiration Date:

Employment History

Please check all Financial Licenses that you currently hold (highlight all that apply Hold the CTRL key and mouse click all that apply)
Series 3 Series 4 Series 6 Series 7 Series 9 Series 10 Series 11 Series 23 Series 24 Series 27 Series 31 Series 32 Series 33 Series 51 Series 53 Series 55 Series 62 Series 63 Series 65 Series 66
Please list two references other than relatives or previous employers:
Name:		Name:
Position:		Position:
Company:		Company:
Address:		Address:
Phone:		Phone:
An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying:
Work Experience: Please list your work experience for the past five years beginning with your most recent job held. If you were self-employed, give firm name.
Name of Employer:		Name of supervisor:
Employer Address:		Employment dates	Start:
Phone:			End:
Reason for leaving?		Last job title:
May we contact this employer? yes  no
Name of Employer:		Name of supervisor:
Employer Address:		Employment dates	Start:
Phone:			End:
Reason for leaving?		Last job title:
May we contact this employer? yes  no
Name of Employer:		Name of supervisor:
Employer Address:		Employment dates	Start:
Phone:			End:
Reason for leaving?		Last job title:
May we contact this employer? yes  no
Upload your Resume:

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				I verify that all information provided is true and accurate
				Signature of applicant
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Dan Ascani is registered with, supervised by, and securities offered through Kovack Securities, Inc.,
Member FINRA/SIPC . Telephone 954-782-4771 . Dan is also a Registered Investment Advisor Representative of Kovack Advisors, Inc.,
which is located at 6451 North Federal Highway, Suite 1201, Ft. Lauderdale, FL 33308