JM STAFFING PRELIM APPLICANT QUESTIONNAIRE

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1 PRELIM APPLICANT QUESTIONNAIRE It s about partnership. It s about people. It s about success. Applicant Name City, State Address 1. Are you telephone accessible? Cell Phone: Home Phone: 2. Do you have reliable transportation? a. If the assignment you re applying for involves driving a motor vehicle: Will you release your driving record (MVR) to us for review? (please attach your drivers license) b. (If for a driving assignment) Do you have your own vehicle? c. (If the answer to b is yes) Will you provide us your personal automobile insurance policy identification card? 3. Do you have your I-9 (work status) information? 4. How did you hear about us or where did we see your resume? 5. What job(s) are you applying for? 6. What areas are you willing to work? 7. For what pay? 8. Do you have current, valid credentials, licenses, and permits (as necessary) to fill the positions for which you are applying (question 4)? a. (If answer to #7 is yes) Will you authorize us to verify your credentials with the appropriate authorities? 9. Are you willing to take a drug test according to our policy? 9. Can you pass a Federal background check; no misdemeanors, felonies, including DUIs? If, please explain 10. Will you release your background information inclusive of criminal records? Applicant Signature

2 554 E. Foothill Blvd., Suite 117 San Dimas, CA Fax It s about partnership. It s about people. It s about success. APPLICANT INFORMATION Last Name First Name M.I. Street Address City State Zip Phone # Cell # Available Social Security # Driver s License # Position applying for: Desired Pay Range: (Hourly/Salary) Type of Work Experience: Administrative/Clerical Accounting/Finance Legal Human Resources Information Technology Other: EDUCATION High School High School Name Address Did you graduate? Degree College College Name Address Did you graduate? Degree Other Education Name Address Did you graduate? Degree F:\Company Shared Folders\Applications, Verification and Background Check Forms\Quick Access for Desktop\Application that gets ed out\employment Application - 6pg.docPage 1 of 6

3 PREVIOUS EMPLOYMENT Job Title Supervisor Name Phone # Address City State Zip Start End Starting Salary Ending Salary Responsibilities: Reason for leaving: May we contact for a reference? Job Title Supervisor Name Phone # Address City State Zip Start End Starting Salary Ending Salary Responsibilities: Reason for leaving: May we contact for a reference? F:\Company Shared Folders\Applications, Verification and Background Check Forms\Quick Access for Desktop\Application that gets ed out\employment Application - 6pg.docPage 2 of 6

4 ADDITIONAL INFORMATION Are you currently employed? Have you ever worked for another temporary agency: If, which one(s): Have you ever been employed with this company before? If, when? Do you have any friends/relatives employed by this company? If, provide their names/relationship to you: Are you currently on lay off status and subject to recall? If hired, can you provide proof of U.S. citizenship or proof of your legal right to work in the U.S.? Are you able to perform all of the essential functions of the job for which you are applying with or without reasonable accommodation? If hired, are there any accommodations the company would need to provide so that you can perform all those essential functions and duties of the position being applied for? If, please explain: If hired, do you have a reliable means of transportation to and from work? How far are you willing to travel: Have you ever been convicted of a felony, misdemeanor, or DUI? If, please explain: List any seminars, classes, or other education which may help qualify you for this position: List any professional, trade, business, or civic activities and offices held. You may exclude membership that would reveal gender, race, religion, national origin, ancestry, age, disability, or any other protected status. Identify formal job training that relates to this position. Identify what skills or certification you possess related to this position. If you are hired, what value would you add to our company? F:\Company Shared Folders\Applications, Verification and Background Check Forms\Quick Access for Desktop\Application that gets ed out\employment Application - 6pg.docPage 3 of 6

5 Describe what you believe are the most unique features of your work history. List any languages other than English that you can speak, read, or write that could be of benefit to the position applied for. REFERENCES References: Three professional and two personal. Professional references must be persons who have supervised your professional work or been associated with you professionally and who know you well. Personal references cannot be family members. Name Title Phone/Address During what years did he/she know you? What was his/her relationship to you professionally? F:\Company Shared Folders\Applications, Verification and Background Check Forms\Quick Access for Desktop\Application that gets ed out\employment Application - 6pg.docPage 4 of 6

6 AFFIRMATIVE ACTION QUESTIONNAIRE (Confidential and Voluntary) JM Staffing is committed to an Affirmative Action Program which includes giving full consideration for employment to qualified individuals without regard to race, color, religion, gender, or national origin. The following information is being requested of all applicants for employment. You re providing this information is strictly voluntary. The self-identification request is made in compliance with the regulations issued by the U.S. Department of Labor. Responses will be used for the purpose set forth in these regulations. Its purpose is to assist JM Staffing in monitoring its Affirmative Action Program and to aid in complying with required Government record keeping and periodic reporting. This information is not part of the employment application. It will be processed separately and will not be considered in the employment/selection process. If you choose to provide information, please complete the following: Applicant Name Position Applying for Social Security Number: Sex: Female Male Race/Ethnicity (check one): American Indian or Alaskan Native A person having origins in any of the original peoples of rth America and South America (including Central America), and who maintains tribal affiliation or community attachment. Asian A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam Black or African American A person having origins in any of the Black racial groups in America Native Hawaiian or other Pacific Islander A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands White A person having origins in any of the original peoples of Europe, rth Africa, or the Middle East Hispanic or Latino (all races) A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race Two or more races: Are you: Disabled Veteran n-veteran Vietnam Veteran I wish to decline Applicant Source of Recruitment (check one): Newspaper Advertising Walk-In Employee Referral. If Employee Referral, name of Employee: Internet. If Internet, website name: MILITARY SERVICE Have you ever been in the armed forces? Are you now a member of the National Guard? Specialty: Entered: Discharge : F:\Company Shared Folders\Applications, Verification and Background Check Forms\Quick Access for Desktop\Application that gets ed out\employment Application - 6pg.docPage 5 of 6

7 DISCLAIMER AND SIGNATURE I agree that I will settle any and all previously unasserted claims, disputes or controversies arising out of or relating to my application or candidacy for employment and/or cessation of employment with JM Staffing, exclusively by final and binding arbitration before a neutral Arbitrator. By way of example only such claims include claims under federal state and local statutory or common law, such as the Age Discrimination in Employment Act, Title VII of the Civil Rights Act of 1964, as amended, including the amendments of the Civil Rights Act of 1991, the Americans with Disabilities Act, the law of contract and the of tort. I agree to these terms Please Read Carefully I do further authorize JM Staffing to investigate, request, and receive any information it deems appropriate, in its sole discretion, relating, to my past employment, education or activities. I indemnify JM Staffing against any liability which may result from such investigation and receipt of information. Any false answer or statement or implication by me to JM Staffing or any of its clients shall be sufficient cause for denial or discharge from any temporary employment which I may secure. If I am temporarily employed by JM Staffing, I agree to strictly obey the work rules and regulations of and regulations as they may occur form time to time. I understand that nothing contained in the application or in the granting of an interview or in any policy practice is intended to create an employment contract between JM Staffing and myself. promise regarding employment have been made to me and I understand that no such promise or guarantee is binding upon JM Staffing. If a temporary employment relationship is established, I understand that such relationship can be terminated at any time by JM Staffing for any reason. I agree to these terms Applicant Signature F:\Company Shared Folders\Applications, Verification and Background Check Forms\Quick Access for Desktop\Application that gets ed out\employment Application - 6pg.docPage 6 of 6

8 JM STAFFING It s about partnership. It s about people. It s about success. EMPLOYMENT VERIFICATION Applicant Name Social Security # Position Held s of Employment Current/Previous Employer Supervisor Address City State Zip Code I hereby give permission to the above named employer to release information to JM Staffing regarding my performance while employed at that facility. Applicant Signature (APPLICANT, complete top section only) EMPLOYER - The person above has registered with JM Staffing and has listed you as a previous employer. We would appreciate your assistance in verifying employment and evaluating job performance. All information is confidential. Title: Personal Evaluation Start : Excellent Above Average Satisfactory End : Below Average Poor Quality of work Quantity of work Attitude Adaptability to work situations Dependability Cooperation Ability to get along with others Attendance and punctuality Personal Appearance Comments Is this employee eligible for rehire? Employer s Signature Print Name Title EMPLOYER, please return the completed form to hr@jmstaffing.com or fax (909) , thank you. For JM Staffing Use Only: Verbal Verification Spoke with Title

9 JM STAFFING It s about partnership. It s about people. It s about success. EMPLOYMENT VERIFICATION Applicant Name Social Security # Position Held s of Employment Current/Previous Employer Supervisor Address City State Zip Code I hereby give permission to the above named employer to release information to JM Staffing regarding my performance while employed at that facility. Applicant Signature (APPLICANT, complete top section only) EMPLOYER - The person above has registered with JM Staffing and has listed you as a previous employer. We would appreciate your assistance in verifying employment and evaluating job performance. All information is confidential. Title: Personal Evaluation Start : Excellent Above Average Satisfactory End : Below Average Poor Quality of work Quantity of work Attitude Adaptability to work situations Dependability Cooperation Ability to get along with others Attendance and punctuality Personal Appearance Comments Is this employee eligible for rehire? Employer s Signature Print Name Title EMPLOYER, please return the completed form to hr@jmstaffing.com or fax (909) , thank you. For JM Staffing Use Only: Verbal Verification Spoke with Title

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