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2008-01-10T14:51:11Z
2008-01-10T15:07:58Z
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Last Name:, Note to Applicants: Only United States Citizens or aliens who have a legal right to work in the United States are eligible for employment. Should you be made an offer of employment, you will be asked to submit documentation verifying your identity and your legal right to work in the United States. Address: Apt. #: City: State: Zip: Home Phone: ( ) Cell Phone: ( ) Pager: ( ) Other Phone: ( )w Emergency Number: ( ) Emergency Contact Name:G How did you hear about PersoNet (if from a friend, list friend's name)? Have you ever filled out an application here before? YES / NO If Yes, when? Month: Year:= Have you ever been previously employed by (Client)? YES / NO7 If YES, please state when, where, and in what position:\ Are you 18 years of age or older? YES / NO If NO, can you furnish a work permit? YES / NOi Education Level (circle one) Some High School / High School Diploma / GED / Some College / College DegreeG ARE YOU LEGALLY ELIGIBLE FOR EMPLOYMENT IN THE UNITED STATES? YES / NOI What areas are you willing to work? What positions are you applying for?| What shifts are you willing to work (circle all that apply)? 1st / 2nd / 3rd / Any / MON / TUE/ WED / THU / FRI / SAT / SUN8 Do you have access to reliable transportation? YES / NO Have you ever been convicted of a felony or misdemeanor? YES / NO (Note: a conviction will not necessarily bar you from employment. Each conviction will be judged on its own merits with respect to time, circumstances, and seriousness.)B ] Have you ever been discharged or suspended from employment? YES / NO If Yes, please explain:D NOTICE TO ALL APPLICANTS: In compliance with the Americans with Disabilities Act of 1990. During the interview process, you may be asked questions concerning your ability to perform job-related functions. If you are given a conditional job offer of employment, you may be required to complete a post-job offer medical history questionnaire and/or undergo a medical examination. If required, all entering employees in the same job category will be subject to the same medical questionnaire and/or examination and all information will be kept confidential and in separate files. Please provide your most recent employment history first. Provide all requested information. If there is any information you are unable to provide, you may be required to return with this information at a later date. Start Date: End Date: Company Name: Company Address: City: State: Zip: Supervisor Name: Title: Phone:$ YOUR Position Title and Description:; Reason for leaving: Starting Salary: Ending Salary:> Are you eligible for rehire? YES / NO If NO, please explain: REFERENCES Please provide us with references we can contact. Professional references are preferred, however, personal references are acceptable after you have listed all of your professional references first. TWO ARE REQUIRED. City: State: Zip:k Name: Address:w Telephone: E-mail:- How many years have you known this reference? Dates verified? YES NO" OFFICE USE ONLY Job titles verified? YES NO References verified? YES NO% CERTIFICATION STATEMENT AND SIGNATUREL I certify that all of the information furnished on this application is true, complete, and correct. I understand and agree that any falsification, misrepresentation, misleading statement, or omission of fact on either the application or during the pre-hire or post-hire process will be sufficient reason for (1) my not being offered employment; or (2) dismissal at any time if I am employed. I authorize you to release the information contained in the background investigation to other firms or persons upon request. I release you, any agency, employer, school, or individual from any liability as a result of such contact. I understand that if employed, my employment will not be for any fixed period of time and may be terminated by the company at any time. I understand that my failure to report for work will indicate that I have quit.w Signature: Date: 2 p
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