Application for Co-Employment This organization is a drug-free workplace and an equal employment opportunity employer. Last Name First Middle

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1 Application for Co-Employment This organization is a drug-free workplace and an equal employment opportunity employer. Last Name First Middle Mailing Address City State Zip code Street Address (if different from above) City State Zip code County of Residence Home phone Message/Cell Phone address Emergency Contact Name Phone Position Applying for How were you referred to us? Please check one. Walk-in Internet Where? Other If hired, can you present evidence that you have the legal right to work in the United States? Yes No Have you ever been employed here? Sepulveda BBSI Dates: Have you been convicted of a felony or Serious Misdemeanor? (Convictions for marijuana-related offenses that are more than two years old need not be listed) Yes No If yes, please explain Wage Desired Are you applying for: Full Time Part Time Temporary Shifts that you are available: Please circle all days you can work Monday Tuesday Wednesday Thursday Friday Saturday Sunday Times available: Date available to start work Are you at least 18 years old? Yes No If no, do you have a work permit? Yes No Are you able to perform the essential functions of the job for which you are applying either with or without reasonable accommodation? Yes No If no, please describe the functions that cannot be performed Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The nature of the offense, date of the offense, surrounding circumstances and the relevance to the position applied for may however be considered. Note: We comply with ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform the essential functions. Education Name of School City and State Field of Study Circle last year completed List Diploma or Degree High School GED Trade School College Masters Skills Language Do you: Speak Read Write Fair Good Fluent Fair Good Fluent Fair Good Fluent Language Do you: Speak Read Write Fair Good Fluent Fair Good Fluent Fair Good Fluent Office/Computer Skills Excel Word Other Please list any special skills, training or education that may be applicable to the position you are applying for:

2 Employer Name Previous Employment Please List most recent employer first Job Title Address Job Duties Supervisor Phone Dates of Employment From To Last rate of pay Reason for leaving: Employer Name Job Title Address Job Duties Supervisor Phone Dates of Employment From To Last rate of pay Reason for leaving: Employer Name Job Title Address Job Duties Supervisor Phone Dates of Employment From To Last rate of pay Reason for leaving: Have you obtained any special skills or abilities as the result of service in the Military? Yes No If yes, please describe: Please add any additional information you may think helpful to your consideration for employment. Please read the following statements carefully, prior to providing signature and date below I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery. I hereby authorize to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the references I have listed to disclose to any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release, my former employers and all other persons, corporations, partnerships and associations forma any an all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure. I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated ant any time, with or without prior notice, at the option of wither myself or and that no promises or representations contrary to the forgoing are binding on unless made in writing and signed by me and the companies designated representative. Should a search of public records (including records documenting an arrest, indictment, conviction, civil judicial action, tax lien, or outstanding judgment) be conducted by internal personnel employed by, I am entitled to copies of any such public records obtained by. If I am not hired as a result of such information, I am entitled to a copy of any such records. I agree to a pre-placement physical examination and drug test at expense. I have read and understood the foregoing and I agree unconditionally to the foregoing. Date Applicant s Signature

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5 FROM: TO: Personnel Manager: The person named below has applied to this company for employment. Your firm is listed by the applicant as a past employer. Kindly reply to this inquiry regarding this applicant. As you will note from the waiver stated below, the applicant has waived any claim of liability against your company (and its agents) for information submitted in response to this inquiry. Please fax your reply to or mail to the address above. Name of applicant: Job applied for: 1. This applicant lists dates of employment with your firm from to is this correct? If no, please explain: 2. What kind(s) of work did he/she do_ 3. If employed as a driver, please indicate type of equipment driven. 4. Would you re-employ this person? 5. Remarks: Signature of person supplying information Title Date WAIVER Prospective Employees Complete this Section (Former Employer) Date_ I hereby authorize you to release all information concerning my employment including oral assessments of my job performance, and salary to each and every company or their authorized agents, which may request such information in connection with my application for employment with said company. I hereby release you from any and all liability of any type as a result of providing the above mentioned information to the above mentioned person. (Applicants signature) (Witness signature)

6 For Office Use Only PROSPECTIVE Pre-Employment EMPLOYYE EMPLOYEE CHECKLIST CHECKLIST Name: Phone: Application complete complete Yes YES No no Offer letter letter Yes YES No no DMV DMV OK OK Yes YES No no n/a n/a clinic: Pre-employment US Healthworks physical physical ok (Gar) ok Yes Eisenhower(CATH. YES No CITY) no Eisenhower. clinic: US Healthworks CP (LQ) (GAR) South EIS. Coast Family Eisenhower(CATH. (LN) SCF CITY) Eisenhower. (LQ) South Coast Family (LN) US Healthworks US (SBX) (SBX) SSB. Industrial Industrial Medical Medical Clinic (LOMPOC) Clinic (LOMPOC) Pre-employment Drug X-ray results ok ok physical Yes YES ok No no n/a YES no X-ray Drug results results ok ok Yes YES No no n/a Drug Awsi AWSI results ok ok Yes YES No no n/a n/a Awsi Frasco results Profiles Profiles (background ok (background check) YES ok check) ok Yes no YES n/a No no n/a n/a Frasco New hire Profiles packet/employee Handbook (background check) ok Date YES no n/a NOTES:_ Start date/new hire packet: Start NOTES:_ date/new hire packet: NOTES:_ Hired Yes No Status Emp. ID # If applicant is 18 years old or less, is proof of age on file? Yes No Start Date Interviewers Name and Signature Immediate Supervisors Name Department Location Full Time Part Time Starting Wage/Salary Exempt Non-Exempt Additional Comments Dept. Approval Date HR Approval Date