Test Results:

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Appointment Date / Time // : Referred to QualStaff by:

Position Applying for:

Last Name / First Name / Middle / Social Security # / Home Phone #
Street Address
City / State / Zip Code / Email Address / Cell Phone #
Emergency Contact #1 / Phone # / Emergency Contact #2 / Phone #
Work Interest: (Mark an “X” in boxes that may apply)

F/T P/T Temporary Long Term Short Term Temp to Hire Direct Hire

Days Available: M T W Th F S Su / Work Hours Available:
AreaCity Preferred: / Commute: (Time or Miles)
Available Start Date: / Comments:

Pace: Fast Moderate Slow Style: Autonomous Interactive Team environment

Personal Strength:
Hourly: / $ / Salary: / $ / (MINIMUM REQUIREMENTS)
High School Diploma/GED? / GPA / Trade School? / School Name:
Professional Training/Certifications:
College Degree? / GPA / College Attended:
Graduate Degree? / In Progress? / GPA / College Attended:
Employer’s Name & Address / Your Position Title / Direct Supervisor / Phone # / Reason For Leaving
Your Position Responsibilities / Your Salary (Hourly or Annually)
$
Interviewer’s Notes / Dates of Employment:
From: To:
Employer’s Name & Address / Your Position Title / Direct Supervisor / Phone # / Reason For Leaving
Your Position Responsibilities / Your Salary (Hourly or Annually)
$
Interviewer’s Notes / Dates of Employment:
From: To:
Employer’s Name & Address / Your Position Title / Direct Supervisor / Phone # / Reason For Leaving
Your Position Responsibilities / Your Salary (Hourly or Annually)
$
Interviewer’s Notes / Dates of Employment:
From: To:
Reference’s Name / Title / Company / Address/City/State/Zip Code / Phone #
1) Were you known to any employer, school or reference by another name? / Yes No
2) Are you at least 18 years of Age? / Yes No
3) If employment is offered, can you submit verification of your legal right to work in the United States? / Yes No
4) Have you ever been dismissed or forced to resign from any employment? / Yes No
If yes, explain:
5) Have you ever been dismissed or forced to resign from any employment for reasons that involved dishonesty or breach of trust (including but not limited to shoplifting, discount abuse, cash handling, robbery, embezzlement, theft, forgery, perjury, tax evasion, falsification of Company documents including timecards, etc)? / Yes No
If yes, explain:
6) Have you ever been convicted of a felony? (Do not identify any felony conviction for which the record has been judicially ordered sealed, expunged, or statutorily eradicated). / Yes No
If yes, explain:
7) Have you ever been convicted of a misdemeanor? (Do not answer "yes" if the conviction record has been judicially ordered sealed, expunged, or statutorily eradicated. Do not answer "yes" if probation for the conviction was successfully completed or discharged and the case was judicially dismissed under Penal Code 1203.4. Do not answer "yes" if your conviction was for a misdemeanor marijuana conviction and is more than 2 years old). / Yes No
If yes, explain:
8) Have you ever served on active duty in the US military service? (Exclude tours of active duty for training as a reservist or guardsman.) / Yes No
9) Have you ever been discharged from the armed service under other than honorable conditions? You may omit any such discharge changed to honorable by a Discharge Review Board or similar authority. / Yes No
If yes, explain:
As an equal opportunity employer, QualStaff Resources does not discriminate in hiring or terms and conditions of employment because of an individual's race, color, sex, national origin, religion, age, disability, or any other legally protected basis. In consideration of my employment, I agree to conform to the rules and regulations of QualStaff Resources. I understand that, as a matter of Company policy, every aspect of my employment relationship with QualStaff Resources is on an at-will basis, meaning that I or QualStaff Resources may terminate my employment at any time, for any reason, with or without cause. As part of this at-will policy, I understand that QualStaff Resources expressly reserves its inherent authority to manage and control the business enterprise and to exercise its sole discretion to determine all issues pertaining to my employment as an Associate of QualStaff Resources. I further understand that any agreement, written or verbal, made contrary to the foregoing will not be valid without written authorization by the Director of Operations of QualStaff Resources and me.
Upon accepting employment, I will be provided with an Orientation Packet. I further acknowledge my understanding that the benefits, policies, and programs stated in the Orientation Packet are provided at Company discretion and may be changed or eliminated at any time, except the policy of at-will employment. If employed, it shall be my responsibility to familiarize myself and follow all Company policies and regulations relating to my employment. In accepting employment I acknowledge that the policies and benefits and other programs as set forth in these documents are not meant to infer or imply a contract of employment for a specified period between the Company and myself, or otherwise change the at-will nature of my employment.
I certify that the information contained in this application is correct to the best of my knowledge. I understand that falsification of any information on this application or a material omission is grounds for immediate dismissal whenever discovered. In considering my application for employment, I authorize the Company to verify the information set forth on this application and obtain any additional information relating to my background it may need to assess my suitability for employment. Accordingly, I authorize all persons, schools, companies, corporations, credit bureaus, and law enforcement agencies to supply the Company with information relating to my background and I do hereby release all such parties who provide information to the Company from any and all liability for damages that may result from furnishing the same.
Applicant Signature: / Date:

REFERENCE FORM

TEMPORARY WORK HISTORY

Start Date / End Date / Job Title / Client / Supervisor’s Name & Title
Pay Rate / Complete Assignment?
If no, please provide reason. / Would you work on another assignment at client?
If no, please provide reason. / Staffing Service / Recruiter
Start Date / End Date / Job Title / Client / Supervisor’s Name & Title
Pay Rate / Complete Assignment?
If no, please provide reason. / Would you work on another assignment at client?
If no, please provide reason. / Staffing Service / Recruiter
Start Date / End Date / Job Title / Client / Supervisor’s Name & Title
Pay Rate / Complete Assignment?
If no, please provide reason. / Would you work on another assignment at client?
If no, please provide reason. / Staffing Service / Recruiter
Start Date / End Date / Job Title / Client / Supervisor’s Name & Title
Pay Rate / Complete Assignment?
If no, please provide reason. / Would you work on another assignment at client?
If no, please provide reason. / Staffing Service / Recruiter

Updated 11/15/06