Sample Employment Application Form

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					                                                                                                 1821 Hillandale Road
                                                                                                      Suite 1B-229
                                                                                                  Durham NC 27705
                                                                                                 Office (919) 794-4127
                                                                                                  Fax (919) 321-6145

                                                                                                 www.Staffinuity.com
                                                                                                 Info@staffinuity.com



                                           APPLICATION FOR EMPLOYMENT



                                                                             DATE _________________________________

Name ______________________________________________________________________________________________
                        Last                      First                      Middle                      Maiden

Present address _____________________________________________________________________________________
                           Number                     Street                 City                        State            Zip

How long? ________ Year(s) ______ Month(s)                        Social Security No. ________ – ______ – _________

Telephone (     __ )                     Alternate Phone ( __    )_______________ E-mail __________________________

Are you at least 18 years old?    Yes    No

                                                                      Days/hours available to work
Position applied for __________________________                       No Preference _ Thur _________
                                                                      Mon _________ Fri __________
Salary desired _____________________________                          Tue __________ Sat __________
                                                                      Wed _________ Sun _________
(Be specific)

How many hours can you work weekly? ________________________           Can you work nights?       Yes       No

Employment desired         FULL-TIME ONLY                PART-TIME ONLY             FULL- OR PART-TIME

When are you available to start working? _________________________



 TYPE OF SCHOOL          NAME OF SCHOOL                LOCATION                  NUMBER OF YEARS                  MAJOR &
                                                (Complete mailing address)         COMPLETED                      DEGREE
High School


College


Bus. or Trade School


Professional School




                                                                                                                   Application 1 of 8
   HAVE YOU LIVED OUTSIDE OF NORTH CAROLINA WITHIN THE LAST FIVE (5) YEARS?  No                        Yes
   HAVE YOU EVER BEEN CONVICTED OF A CRIME?                       No          Yes
   HAVE YOU EVER PLEAD GUILTY OR NO CONTEST TO ANY CRIME?

   If yes, explain: _______________________________________________________________________________________

    _________History & Background Check does NOT automatically exclude you from employment consideration _____

                                                       Confidential
                                 History and Background Check Authorization


Print Name: _____________________________________________________________________________________________
                   (First)                                 (Middle)                                        (Last)


Former Name(s) and Dates Used: ___________________________________________________________

Current Address Since: ___________________________________________________________________
                              Mo/Yr)            (Street)                     (City)                          (Zip/State)


Previous Address From: __________________________________________________________________
                              (Mo/Yr)           (Street)                     (City)                          (Zip/State)


Social Security Number: ______-______-______

Date of Birth: ___/____/____

Telephone Number: (___) ____-______ and/or (___) ____-______

Drivers License Number: __________________ State Issued: ________________
                                                   Please Read Carefully:
        The information contained in this application is correct to the best of my knowledge. I hereby authorize
             STAFFINUITY LLC and its designated agents and representatives to conduct a comprehensive
       Review of my background causing a Consumer Report and/or an Investigative Consumer Report to be
          generated for employment and/or volunteer purposes. I understand that the scope of the Consumer
      Report / Investigative Consumer Report may include, but is not limited to the following areas: verification of
         social security number; current and previous residences; employment history, education background,
       character references; drug testing, civil and criminal history records from any criminal justice agency in
       Any or all federal, state, county jurisdictions; driving records, birth records, and any other public records.
          I further authorize any individual, company, firm, corporation, or public agency (including the Social
          Security Administration and law enforcement agencies) to divulge any and all information, verbal or
         written, pertaining to me, to STAFFINUITY LLC or its agents. I further authorize the complete release
           of any records or data pertaining to me which the individual, company, firm, corporation, or public
                      agency may have, to include information or data received from other sources.
            I hereby release STAFFINUITY LLC, the Social Security Administration, and its agents, officials,
              representative, 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 any
         Time, result to me, my heirs, family, or associates because of compliance with this authorization and
                                                     Request to release.

          Signature: ______________________________________ Date: ______________




                                                                                                             Application 2 of 8
     PLEASE PRINT ALL
 INFORMATION REQUESTED
    EXCEPT SIGNATURE
                                             APPLICATION FOR EMPLOYMENT


DO YOU HAVE A DRIVER’S LICENSE?                Yes     No

What is your means of transportation to work? ______________________________________________________________

Driver’s license
number ____________________________ State of issue _______                   Operator      Commercial (CDL)       Chauffeur

Expiration date ______________________


Please list two professional references.

Name ________________________________________                     Name ____________________________________________

Position ______________________________________                   Position __________________________________________

Company _____________________________________                     Company _________________________________________

Address ______________________________________                    Address __________________________________________

         ______________________________________                            __________________________________________

Telephone (    ____)                                              Telephone ( ___ )



An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the
space below to summarize any additional information necessary to describe your full qualifications for the specific position for
which you are applying.




                                                                                                                    Application 3 of 8
     PLEASE PRINT ALL
 INFORMATION REQUESTED
    EXCEPT SIGNATURE
                                            APPLICATION FOR EMPLOYMENT

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


Name of employer                                                   Name of last       Employment dates        Pay or salary
                                                                    supervisor
Address
                                                                                      From                 Start

City, State, Zip Code                                                                 To                   Final


Phone number                                                    Your last job title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this
company.




Name of employer                                                   Name of last       Employment dates        Pay or salary
                                                                    supervisor
Address
                                                                                      From                 Start

City, State, Zip Code                                                                 To                   Final


Phone number                                                    Your last job title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this
company.




May we contact your present employer?         Yes     No




                                                                                                                   Application 4 of 8
     PLEASE PRINT ALL
 INFORMATION REQUESTED
    EXCEPT SIGNATURE
                                            APPLICATION FOR EMPLOYMENT


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


Name of employer                                                   Name of last           Employment dates     Pay or salary
                                                                    supervisor
Address
                                                                                          From               Start

City, State, Zip Code                                                                     To                 Final


Phone number                                                    Your last job title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this
company.




Name of employer                                                   Name of last           Employment dates     Pay or salary
                                                                    supervisor
Address
                                                                                          From               Start

City, State, Zip Code                                                                     To                 Final


Phone number                                                    Your Last Job Title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this
company.




                                                        OFFICE ONLY


              Yes                                            Yes                    Word            Yes
Typing        No            _____ WPM                10-key  No                     Processing      No        _____ WPM

Personal      Yes         PC                                  Other ____________________________________________




                                                                                                         Application 5 of 8
                            PLEASE READ CAREFULLY

Computer    No   Mac                 Skills ____________________________________________
                             APPLICATION WAIVER




                                                                       Application 6 of 8
In exchange for the consideration of my job application by Staffinuity , 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 Staffinuity LLC practices, shall serve to create an actual
or implied contract of employment, or to confer any right to remain an employee of Staffinuity
LLC, or otherwise to change in any respect the employment-at-will relationship between it and the
undersigned, and that relationship cannot be altered except by a written instrument signed by the
Director of Staffinuity LLC. Both the undersigned and the Staffinuity LLC may end the
employment relationship at any time, without specified notice or reason. If employed, I
understand that the Staffinuity LLC may change or revise their benefits, policies and procedures
and such changes may include reduction in benefits.
I authorize investigation of all statements contained in this application. I understand that the
misrepresentation or omission of facts called for is cause for dismissal at any time without any
previous notice. I hereby give Staffinuity LLC permission to contact schools, previous employers,
references, and others, and hereby release Staffinuity LLC from any liability as a result of such
contract. I also authorize for this information to be disclosed to client companies in consideration
of being placed on an assignment with the client company and to comply with regulations by
which the client company must adhere.
I also understand that (1) Staffinuity LLC has a drug and alcohol policy 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 understand that, in connection with the processing of your employment application, Staffinuity
LLC may request from a consumer reporting agency an investigative consumer report including
information as to my credit records, character, general reputation, personal characteristics, and
mode of living. Upon written request from me, Staffinuity LLC will provide me with additional
information concerning the nature and scope of any such report requested by it, as required by
the Fair Credit Reporting Act.




______________________________________
___________________________________
Signature of applicant                                                     Date




   Staffinuity LLC 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 Staffinuity LLC depends solely on your qualifications.



         Thank you for completing this application form and for your interest in our business.




                                                                                                              Application 7 of 8
Application 8 of 8

				
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