Action Staffing Inc. | Premier Staffing Solutions in Indiana

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EMPLOYMENT APPLICATION

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APPLICANT INFORMATION

Last Name:

First Name:

M.I.

Date of Birth:

Street Address:

Apt./Unit:

City

State:

Zip Code:

Phone:

Email:

Contact Phone #:

Available Date:

Desired Hourly Wage ($)

Position Applied For:

Are you a citizen of the United States?

If no, are you authorized to work in the U.S.?

Have you ever worked for this company?

If so, when?

Have you ever been convicted of a felony?

If so, explain:

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EDUCATION

High School:

City/State:

Did you graduate?

From:

To:

College:

City/State:

Did you graduate?

From:

To:

Other:

City/State:

Did you graduate?

From:

To:

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PERSONAL REFERENCES

Please list two personal references - not former employers or supervisors

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Reference #1

Full Name:

Relationship:

Company:

Phone Number:

Address:

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Reference #2

Full Name:

Relationship:

Company:

Phone Number:

Address:

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PREVIOUS EMPLOYMENT

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Previous Employer #1

Company:

Phone Number:

Address:

Supervisor:

Job Title:

Starting Salary ($):

Ending Salary ($):

Responsibilities:

From:

To:

Reason for Leaving:

May we contact your previous supervisor as a reference?

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Previous Employer #2

Company:

Phone Number:

Address:

Supervisor:

Job Title:

Starting Salary ($):

Ending Salary ($)

Responsibilities:

From:

To:

Reason for Leaving:

May we contact your previous supervisor for a reference?

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MILITARY SERVICE:

Branch:

From:

To:

Rank at Discharge:

Type of Discharge:

If other than honorable, please explain:

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PERSONAL INFORMATION

Do you have reliable transportation to and from work?

Are you available to work overtime?

Do you have friends or relatives employed with us?

If so, please list the names:

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DISCLAIMER AND SIGNATURE

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By typing my name below, I am electronically signing and certifying that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my termination.

Name:

Date:

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