|
APPLICATION
FOR EMPLOYMENT
GENERAL
INFORMATION |
| Name Last, First,
M.I. |
 |
| Date |
|
| Temporary/Permanent |
|
| Email |
|
| Social Security # |
|
| Referred by |
|
|
Permanent Address |
| Street |
|
| City |
|
| State |
|
| Zip Code |
|
| Home Phone |
|
| Work Phone |
|
| Pager/Beeper |
|
| Mobile Phone |
|
| In Case of
Emergency: |
| Contact Phone #1 |
|
| Contact Phone #2 |
|
| Mailing Address
(if different from permanent
address) |
| Street |
|
| City |
|
| State |
|
| Zip Code |
|
| Are you presently employed? |
Yes
No
|
| May we contact your employer? |
Yes
No
|
| EDUCATION & TRAINING |
| College/University |
|
| City |
|
| State |
|
| Degree Received |
|
| Date Received |
|
| College/University |
|
| City |
|
| State |
|
| Degree Received |
|
| Date Received |
|
| Additional
Professional Training |
| Institution |
|
| City |
|
| State |
|
| Certificate Received |
|
| Date Received |
|
| Employment History (List present or last job
first) |
| Employer |
|
| Street Address |
|
| City/State/Zip |
|
| Dates Employed |
|
| Reason for leaving |
|
| Position/Title |
|
| Unit/Floor |
|
| Supervisor |
|
| Telephone |
|
| Salary |
|
| Employer |
|
| Street Address |
|
| City/State/Zip |
|
| Dates Employed |
|
| Reason for leaving |
|
| Position/Title |
|
| Unit/Floor |
|
| Supervisor |
|
| Telephone |
|
| Salary |
|
| Employer |
|
| Street Address |
|
| City/State/Zip |
|
| Dates Employed |
|
| Reason for leaving |
|
| Position/Title |
|
| Unit/Floor |
|
| Supervisor |
|
| Telephone |
|
| Salary |
|
| Employer |
|
| Street Address |
|
| City/State/Zip |
|
| Dates Employed |
|
| Reason for leaving |
|
| Position/Title |
|
| Unit/Floor |
|
| Supervisor |
|
| Telephone |
|
| Salary |
|
| Employer |
|
| Street Address |
|
| City/State/Zip |
|
| Dates Employed |
|
| Reason for leaving |
|
| Position/Title |
|
| Unit/Floor |
|
| Supervisor |
|
| Telephone |
|
| Salary |
|
Military Experience
Complete if you
served in the United States Armed Forces |
| Branch |
|
| Active Duty From |
|
| Active Duty To |
|
| Discharge other than honorable? |
No
Yes
|
| If yes explain |
|
| Describe your duties and special training |
|
| [Disclosure of
dishonorable or general discharge will not necessarily
disqualify application or termination after
employment.] |
| BACKGROUND |
| Have you ever been
convicted of a crime (misdemeanor or felony) other than a
minor traffic violation, within the past seven (7) years? A
conviction includes a plea, verdict, or finding of guilt
regardless of whether sentence is imposed by the
court. |
|
Yes
No
|
| If yes: |
|
| Where? |
When? |
| Charge: |
Sentence: |
| (Disclosure of a
criminal record will not necessarily disqualify you for
employment; however, failure to disclose such information may
result in disqualification of your application or termination
after employment.) |
| Do you have a valid driver's license? |
Yes
No
|
| License No. |
State |
| Expiration Date
|
| Has your driver’s license ever been suspended or
revoked? |
Yes
No
|
| Have you been cited for a traffic violation of
any kind in the past five years? |
Yes
No
|
If yes, give details:
|
|
IMPORTANT: PLEASE READ
CAREFULLY
I certify that, to the best of my knowledge,
all the information provided to Rapid Temps, Inc.
hereforth, in this application packet and in any future
communication, is true and complete. I understand that any
misrepresentation, falsification or willful omission may
result in a refusal of employment or dismissal after
employment. I understand that a routine inquiry may be made
during the processing of this application so as to acquire
information concerning my employment record, education,
licensure, certification, general reputation, character,
background and work performance. I authorize educational
institutions, employers, law enforcement authorities,
organizations and individuals having relevant information
concerning me to release such information. I release all
concerned from any liability in connection therewith.
Furthermore, I understand that if I am
employed, my employment and compensation can be terminated,
with or without cause or notice and at any time, at the option
of either the company or myself. I understand that any
employee manuals, handbooks or policy statements that effect
employment are subject to change at any time and shall not be
construed as a contract or a guarantee of continued
employment. No representative of the company, other than the
Chief Executive Officer of Rapid Temps, Inc. or one
designated by the Chief Executive Officer, has any authority
to enter into any agreement for employment for any specific
period of time, or to make any agreement contrary to the
foregoing.
I understand that many of the medical
facilities served by Rapid Temps, Inc. require a
physical examination and/or drug testing of personnel and that
I may be asked to participate as a condition of placement.
By submitting this Application
electronically, I agree that the same constitutes my signature
to this Application, and Rapid Temps, Inc. may rely upon the
same as an electronic signature. |
© Rapid Temps, Inc, rev
12-99
- Required field
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