SELECT STAFF FULL WORK APPLICATION
First Name: / Middle Name: / Last Name: Date:Application for position of: / Date Available: / E-Mail Address:
Present Address(number, street, city, state, zip code): / Home Phone:
Mailing Address (If different from above): / Emergency Phone:
What hours are you available to work?
A.M. P.M. / Types of Employment Preferred (Check more than one box if desired)
Permanent (Full-time) Permanent (Part-time)
Temporary (Full-time) Temporary (Part-time)
Until: Until:
What Days are you available to work?
Monday Tuesday Wednesday
Thursday Friday Saturday Sunday
Do you have access to a car? (For some positions a vehicle is required.) Yes No
Do you have a valid driver’s license? Yes No
Are you over 18? Yes No
Do you have legal authorization to work in this country? Yes No
Are you a veteran? Yes No
EDUCATION AND TRAININGCheck the box next to the highest grade or year completed in school:
1 2 3 4 5 6
7 8 9 10 11 12 / Do you have a High School Diploma, HSED, or GED?
Yes No
Name and Location of High School:
TRAINING BEYOND HIGH SCHOOL (College or University, Nursing, Business College, or other schools you have attended.) Under credits earned, indicate Q for Quarter Hours and S for Semester Hours. / Check the box next to the number of years in college or university:
1 2 3 4 5 6
7 8 9 10 11 12
Name and location / Dates Attended
From / To
/ Credit Earned / Major Field / GPA/Base / Degree (and Year) Conferred
Describe any education or training you have had which is not covered above, such as vocational schools, correspondence courses, service schools, in-service training, or volunteer work which you feel is relevant to the job or jobs for which you are applying. Also, include relevant licenses or certificates. Be specific.
List any organizations you belong to (or have belonged to) and any job-related honors or awards you have received:
WORK EXPERIENCE:Provide a complete description. This information will be used to determine if your application is accepted. Be specificwith your most recent job and attempt to include employment occurring over the past 10 years. BE CERTAIN TO INCLUDE SERVICE IN THE ARMED FORCES. For part-time work, list the average number of hours per month. Indicate any changes in job title under same employer as separate position. Use additional pages if necessary to complete this section.
Employer / Kind of Business / Street Address
Your Title / Reason for Leaving / City, State, Zip Code
Your Duties
/ Name of Supervisor
Total Time Employed
From (month, year)
Check Monthly Salary Beginning : $
One: Hourly Salary Ending $
Employer / Kind of Business / Street Address
Your Title / Reason for Leaving / City, State, Zip Code
Your Duties
/ Name of Supervisor
Total Time Employed
From (month, year)
Check Monthly Salary Beginning : $
One: Hourly Salary Ending $
Employer / Kind of Business / Street Address
Your Title / Reason for Leaving / City, State, Zip Code
Your Duties
/ Name of Supervisor
Total Time Employed
From (month, year)
Check Monthly Salary Beginning : $
One: Hourly Salary Ending $
Employer / Kind of Business / Street Address
Your Title / Reason for Leaving / City, State, Zip Code
Your Duties
/ Name of Supervisor
Total Time Employed
From (month, year)
Check Monthly Salary Beginning : $
One: Hourly Salary Ending $
May we communicate with your present employer? Yes No May we communicate with your past employers? Yes No
REFERENCES:
Name: / Address: / Telephone:Name: / Address: / Telephone:
Name: / Address: / Telephone:
Signature / Date Signed:
Information furnished on this application is subject to verification. This information will be used to determine your qualifications. Misrepresentation of data could result in rejection as a candidate or subsequent dismissal if employed.
Is there a criminal charge, felony or misdemeanor currently pending against you which would substantially relate to the position you are applying for?
Yes or No If yes, please give a brief description of the pending charge.
Have you ever been convicted of a crime, felony or misdemeanor? Yes or No
If yes, please give a brief explanatory statement.
Have you ever been convicted of a crime, felony or misdemeanor in any other state or country Yes or No
If yes, please give a brief explanatory statement.
A conviction or an arrest will not necessarily disqualify you from employment. It will be considered only as it relates to the job you are seeking.
Authorization to Obtain a Consumer Credit Report and
Release of Information for Employment Purposes
Pursuant to the Federal Fair Credit Reporting Act, I hereby authorize Select Staff and its designated agents and representatives to conduct a comprehensive review of my background through a consumer report and/or an investigative consumer report to be generated for employment, promotion, reassignment or retention as an employee. I understand the scope of the consumer verification of Social Security number; current and previous residence; employment history, including all personnel files; education; references; credit history and reports; criminal history, including records from any criminal justice agency in any or all federal, state or county jurisdictions; birth records; motor vehicle records, including traffic citations and registration; and any other public records.
I, , authorize the complete release of these records or data pertaining to me which an individual, company, firm, corporation or public agency may have. I understand that I must provide my date of birth to adequately complete said screening and acknowledge that my date of birth will not affect any hiring decisions. I hereby authorize and request any present of former employer, school, police department, financial institution or other persons having personal knowledge of me to furnish Select Staff or its designated agents with any and all information in their possession regarding me in connection with an application of employment. I am authorizing that a photocopy of this authorization be accepted with the same authority as the original.
I hereby release Select Staff and its agents, officials, representatives or assigned agencies, including officers, employees or related personnel, both individually and collectively, from any and all liability for damages of whatever kind, which may at anytime result to me, my heirs, family or associates because of compliance with this authorization and request to release. You may contact me as indicated below. I understand that a copy of this authorization may be given at any time, provided I do so in writing.
I understand that, pursuant to the Federal Fair Credit Reporting Act, if any adverse action is to be taken based upon the consumer report, a copy of the report and a summary of the consumer’s right will be provided to me. I further understand that such report will be made available to me prior to any such decision being made, along with the name and address of the reporting agency that produced the report.
Please Print Clearly
1. Name (Full)
2. Print All Former Names Used (A)
(B)
3. Social Security Number
4. Date of Birth
5. Telephone Number
6. Current Street Address
7. City State Zip
8. Driver’s License Number State Issues
9. Name on Driver’s License
10. May we contact your employers?
11. May we contact your supervisors?
12. Prior residence, past seven (7) years
i.)
From To
ii.)
From To
iii.)
From To
By signing below, I acknowledge that I have read and understand the statements above. I am also certifying that the above information is true and correct.
Signature
Date
Reference Check Form
I authorize Select Staff to make any inquiry of or receive information from any person or organization regarding my suitability for employment and do hereby give permission to these persons or organizations to provide such information.
I understand that if I misrepresent or omit facts on my application that this is cause for dismissal from Select Staff if I have been employed.
I hereby release Select Staff and my previous employers from any and all liability for damages of whatever kind for providing information given regarding my employment history with their company.
I acknowledge that I have read and understand the statements above.
Signature
Date
DRUG AND ALCOHOL POLICY
Select Staff is committed to maintaining a workplace free from the effects of alcohol and drugs, and ensuring the public that their safety and trust in us is protected. Accordingly, the following work safety rules are hereby established
A. No employee shall be under the influence of alcohol or illegal drugs at any time during working hours.
B. The sale, possession, use, transfer or purchase of illegal drugs by Select Staff employees, both on and off duty, substantially impacts upon and affects the employment relationship and is, therefore, strictly prohibited.
C. Consumption of alcohol or illegal drugs by an employee on duty is not allowed. This policy includes any paid or unpaid lunch periods in the normal work day, normal hours of training sessions or conferences and at all Select Staff sponsored events.
D. When using a company vehicle, either on or off duty, the use of alcohol or illegal drugs is prohibited.
E. An employee is also prohibited from reporting for duty or remaining on duty when the employee uses any controlled substance, including prescription medications, except when the use is pursuant to the instructions of a licensed health care provider who has advised the employee that the substance does not adversely affect the employee’s ability to safely and competently perform his/her job. Employees must report to their supervisor when they are taking any prescription or over-the-counter medication known to cause dizziness or drowsiness or that might affect their senses, motor ability, judgment, reflexes or otherwise affect their ability to perform their job.
The purpose of these work rules is: (a) to establish and maintain a safer, healthier working environment; (b) to help reduce the number of and potential for industrial injuries; (c) to aid in reducing absenteeism and tardiness; and, (d) to improve job performance.
In order to promote compliance with this policy, the Client Companies of Select Staff reserve the right to search any part of its premises at any time to determine the physical presence of drugs and/ or alcohol on property of the Company.
Failure to comply with any part of this policy may result in a withdrawal of any conditional job offer for job applicants, and in discipline, up to and including, termination for employees.
A positive drug or alcohol test result for any reason may lead to discipline, up to and including, discharge from employment.
To effectuate this Policy, the Company will test applicant and employees for drugs and/or alcohol under the circumstances outlined below. Any drug/alcohol test performed shall be conducted within guidelines established under the DOT’s Workplace Drug Testing Program regulations or other acceptable guidelines concerning specimen collection, labeling, and protection; chain of custody; use of an approved confirmation test; and the confidentiality of test results. Any testing facility selected by Select Staff, upon request, must complete the applicable DWD forms certified by the specimen collector and drug testing laboratory, to be used as evidence in unemployment compensation proceedings.
A. Random testing. This test is used in order to eliminate risks associated with illegal or unauthorized drug and/or alcohol use. Random alcohol and drug testing may be conducted at the discretion of Select Staff and/or the Client Company. The testing dates and times will be unannounced and may be scheduled with unpredictable frequency throughout the year. An employee selected for random testing will be required to immediately proceed to the testing facility.
B. Post work-related injury testing. Select Staffwill require that any employee involved in a work-related accident submit to an alcohol and/or drug test as soon as possible after the accident, but no later than eight (8) hours for alcohol or thirty-two (32) hours for drug testing. Any employee involved in a reportable accident shall notify Select Staff and the Client Company at the first available opportunity after the accident, at which time the employee will be advised to report to an appropriate collection site for testing.
In the event an employee is seriously injured and unable to report to the collection site, the employee shall authorize the health care provider to release to Select Staff any information necessary to indicate the presence of alcohol or any controlled substance in the employee’s system.
C. Reasonable suspicion testing. Select Staff and/or the Client Company will require that an employee be tested, upon reasonable cause, for the use of controlled substance or alcohol. An employee shall submit to testing when requested to do so by Select Staff and the Client Company. Select Staff and the Client Company will presume a positive test result if an employee refuses to be tested upon reasonable cause.
When possible, the reasonable cause circumstances should be witnessed by at least two (2) supervisors who have received training in the detection of probable drug or alcohol use through observations. The reasonable suspicion determination shall be documented and should be completed at the time of the observations, but in no case later than twenty-four (24) hours after the initial reasonable cause observation.
Reasonable cause means a belief drawn from facts or circumstances and inferences from those facts or circumstances sufficient to lead a reasonable person to suspect that the employee is using a controlled substance or alcohol. Examples of reasonable cause include, but are not limited to:
1. Direct observation of physical symptoms;
2. Pattern of abnormal conduct or erratic behavior;
3. Arrest or conviction for drug or alcohol-related offenses;
4. Information from credible and reliable sources; and
5. Evidence of employee tampering with drug or alcohol tests.
D. Pre-employment/placement testing. Prior to working at a specified work site, or as a condition to being hired by a Client Company of Select Staff as the Client Company’s employee, an employee candidate may be required to undergo a drug test upon request in addition to customer placement testing. The employee candidate will be required to immediately proceed to the testing facility before being assigned to the work site or after a conditional offer of employment is made. If the results are positive, the employee candidate shall not be hired by Select Staff or Select Staff’s Client Company and will not be eligible for hire or rehire by Select Staff for one (1) year following the date of the failed drug screen.