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Drug Screen BGü

APPLICATION FOR EMPLOYMENT PLEASE PRINT ALL INFORMATION REQUESTED APPLICANTS WILL BE TESTED FOR ILLEGAL DRUGS BEFORE HIRING PLEASE COMPLETE PAGES 1-4. DATE __________________________

SS #. _______ – _____ – _________ Last First

Name as it appears on Social Security card: ___________________________________________________

Physical address _______________________________________________________________________________________ Number Street City State Zip

Mailing address _______________________________________________________________________________________

How long at present address _____________ E-mail address __________________________________________

Telephone: #1 (_____)_________________________ q Home q Cell qOther ____________________

#2 (_____)_________________________ q Home q Cell qOther ____________________

#3 (_____)_________________________ q Home q Cell qOther ____________________

If under 18, please list age: ________ Referred by: __________________________________________

Position/Company (1) _____________________________________ applied for (Be specific) (2) ____________________________________

Salary desired $ _________________/hour What shift can you work? 1st 2nd 3rd Weekend (Check all that apply)

Personal Information (Optional): Height ____________ Citizen of U.S. Weight ____________ q Yes q No Date of Birth ____________

Person to be notified in case of emergency:

Name _______________________________________________________ Telephone ( )

Address _____________________________________________________ Relationship __________________________

DO YOU HAVE A HIGH SCHOOL DIPLOMA OR GED? q Yes q No TYPE OF SCHOOL NAME and LOCATION OF SCHOOL

(city, state) HIGHEST GRADE COMPLETED

GED/DIPLOMA MAJOR/DEGREE

High School

College

Bus. or Trade School

Are you, or have you ever been, in any branch of the military? q Yes q No Branch__________________________

Do you have a valid Alabama Drivers License? q Yes q No What is your means of transportation to work? ______________________________________________________________ Driver’s license number ____________________________ State of issue _______ q Operator q Commercial (CDL) Expiration date _____________________ Has your Drivers License ever been revoked or suspended?q No q Yes

Have you ever failed a drug screen or test? q No q Yes ___________________________________________

If yes, please give details _______________________________________________________________________________

Middle

Number Street City State Zip

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APPLICATION FOR EMPLOYMENT PLEASE PRINT ALL INFORMATION REQUESTED EXCEPT SIGNATURE

WORK EXPERIENCE

Please list your work experience beginning with your most recent job held. If you were self-employed, give firm name. Attach additional sheets if necessary.

DATE: MONTH/YEAR NAME AND ADDRESS OF EMPLOYER SALARY POSITION REASON FOR LEAVING

From: To: From: To: From: To: From: To: From: To:

List other skills or training:

CHARACTER REFERENCES: Please list three references other than relatives or previous employers.

NAME PHONE NUMBER EMPLOYER YEARS KNOWN

CONTACT REFERENCES: Please list three people we can call if we need to contact you.

NAME PHONE NUMBER EMPLOYER YEARS KNOWN

Have you ever been convicted in a court of law or pleaded no contest; or been fined by any court of law or pleaded no contest; or been fined by any court in connection with any felony, misdemeanor, or other violation (not including parking or other minor traffic tickets); or are you currently awaiting disposition of any similar charges pending against you?

No Yes

If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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APPLICATION FOR EMPLOYMENT PLEASE PRINT ALL INFORMATION REQUESTED EXCEPT SIGNATURE

PLEASE READ CAREFULLY

APPLICATION FORM WAIVER

In exchange for the consideration of my job application by Quality Staffing Solution, Inc. (hereinafter called “the Company”), I agree that:

Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of Quality Staffing Solution, Inc., or otherwise to change in any respect the employment-at-will relationship between it and the undersigned. Both the undersigned and Quality Staffing Solution, Inc. may end the employment relationship at any time, without specified notice or reason unless otherwise specified. If employed, I understand that the Company may unilaterally change or revise their policies and procedures.

I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for non-consideration or dismissal at any time without any previous notice. I also authorize this Company to release the information contained herein and its findings and work history of my employment to other firms or persons on request. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contact.

I also understand that (1) the Company has a substance abuse policy that provides for pre-employment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations.

I authorize Quality Staffing Solution, Inc. to examine any and all criminal records and arrests on file in the cities and counties in the State of Alabama or any other state. In doing so, I understand that I am waiving my right of confidentiality concerning my criminal history.

Did you complete this application yourself? Yes No

Signature of Applicant__________________________________________ Date: ___________________

Print Name __________________________________________

This Company is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications.

We sincerely appreciate your taking the time to fill out this application. We will do our best to find you gainful employment. Our employees are our greatest asset.

PLEASE COMPLETE THE SKILLS INVENTORY ON PAGE 4 OF THIS APPLICATION.

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SKILLS CATEGORIES Please review the following skills categories and choose the areas where you feel your skills are strongest. Check only the boxes that show your actual job experience. 1 MANAGEMENT 4 SALES 6 CRAFT WORKERS 7 OPERATIVES

Manager Sales Associate Mechanic Truck Drivers

Supervisor Service Sales Machinist Forklift Drivers

Foreman Customer Service Electrician Assembly Line

Cashiers HVAC Production Worker

Insurance Agent Carpenter Heavy Equipment Operator

2 PROFESSIONALS Real Estate Broker Welder Industrial Sewing

CPA/Accountant Stock Broker Plumber Overhead Crane

Architects Mason Operator

Registered Nurse Auto Body

Engineer 5 OFFICE AND CLERICAL Fiberglass 8 LABORERS

Pilot General Office Woodworking Warehouse

Surveyor Secretary

Secretary

Injection Molding Scanner

Physical Therapist Bookkeeper Industrial Maintenance Inventory Control

Purchasing Agent Payable/Receivable PEX Stock Clerk

Credit/Collection Brake Press Utility Helper

Payroll Sheet Metal

3 TECHNICIANS Microsoft Office Tool & Die

Computer Programmer Excel

Licensed Practical Nurse Power Point

Drafter/Illustrator Receptionist

Auto Cad QuickBooks

Electronics Technician

9 SERVICE WORKERS

Law Enforcement

Firefighter

Security Guard

Food Service

Janitorial

Personal Assistant

CNA

FOR OFFICE USE ONLY

COMPANY

DEPARTMENT

SUPERVISOR

HIRE DATE

RATE OF PAY

SHIFT

LAST DAY WORKED

REASON FOR

TERMINATION

REHIRE?