DIRECT HIRE STAFFING Employment Application APPLICANT INFORMATION Last Name First M.I. Date Street Apartment/Unit # City State ZIP Date Available Position Applied for Social Security No. E-mail Desired Salary Are you a citizen of the United States? YES NO Have you ever worked for this company? Have you ever been convicted of a felony? YES NO If so, when? YES NO If no, are you authorized to work in the U.S.? If yes, explain YES NO EDUCATION High School From To Did you graduate? YES NO Degree College From To Did you graduate? YES NO Degree Other From To Did you graduate? YES NO Degree REFERENCES Please list three professional references. Full Name Company Relationship Full Name Company Relationship Full Name Company Relationship
PREVIOUS EMPLOYMENT Company Supervisor Job Title Starting Salary $ Ending Salary $ Responsibilities From To Reason for Leaving May we contact your previous supervisor for a reference? Company YES NO Supervisor Job Title Starting Salary $ Ending Salary $ Responsibilities From To Reason for Leaving May we contact your previous supervisor for a reference? Company YES NO Supervisor Job Title Starting Salary $ Ending Salary $ Responsibilities From To Reason for Leaving May we contact your previous supervisor for a reference? MILITARY SERVICE YES NO Branch From To Rank at Discharge Type of Discharge If other than honorable, explain DISCLAIMER AND SIGNATURE I certify 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 release. Signature Date NOTICE TO APPLICANTS Employer complies with the Americans with Disabilities Act of 1990. During the interview process, you may be a s k ed questions concerning your ability to perform job related functions. If you are given a conditional offer of employment, you may be required to complete a post-job offer medical questionnaire and/or undergo a medical examination. If required, all new employees in the same job category will be subject to the same medical questionnaire and/or undergo a medical examination, and all information will be kept confidential in separate files. Employer is an equal opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, sex, religion, national origin, or marital status. We assure you that your opportunity for employment with Employer depends solely upon your qualifications.
ABSENT/SICK PROCEDURES As your employer we understand that at times you will have to be absent from work. In order to insure that our clients are properly covered, we would like you to follow these procedures: 1. We request at least (2) hours notice before your scheduled start time. This will provide us with enough time to obtain a replacement if necessary. 2. You must call the office in which you work with to report your absence. We also recommend that you contact someone personally before the end of the day to confirm that your message was received. Otherwise, you might be considered a no call no show. 3. Leave a detailed message (speak slowly & clearly) and include the following information: Name (First and last), last four numbers of your social security number, facility you work in, name of your supervisor and the reason why you will be absent or late. 4. Employer will retrieve messages on daily bases and notify supervisors of absences. 5. Please be aware that any absence (excused or unexcused) within your first 2 weeks of starting employment can end your assignment. Your assignments will also be ended for excessive absences. After 3 days, a no call/no show will immediately end your assignment. 6. Please be aware that calling in sick does not excuse excessive absences. Employee Name Signature Date
CONDITIONAL JOB OFFER MEDICAL QUESTIONNAIRE All persons are required to furnish health condition information and if necessary, submit to an examination by a company designated physician. This information will be used to determine appropriate job placement. It shall not be used to disqualify an otherwise qualified person who may have a mental or physician disability. These questions pertain only to the essential functions of the job. 1. Do you have any condition or have you sustained any injury that would have an effect on your capacity to perform the duties of this position with or without reasonable accommodations? Yes No By completing and signing this form, I am verifying that employer has already presented a conditional job offer for me. _ Signature of Employee: Date: Signature of Employer: Date: Note: All potential employees will be asked these questions.
CONSENT TO CONTROLLED SUBSTANCE AND/OR ALCOHOL TESTING AND AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION Upon and offer of employment, you may be asked to consent to a drug test. A negative result is required as a condition of employment. PLEASE READ THIS DOCUMENT CAREFULLY. BY SIGNING BELOW, YOU ARE CONSENTING TO SUBMIT TO CONTROLLED SUBSTANCE AND/OR ALCOHOL TESTING AND TO AUTHORIZING THE RELEASE OF HEALTH INFORMATION RELATED TO SUCH TESTING. I, the undersigned employee, have been informed of the bases of employer's Substance Free Workplace Policy ("Policy"); I have been requested to submit to a controlled substance and/or alcohol test. I understand that if I fail to comply with this request I will not be considered for employment. I also understand that if I receive a "positive" test result or a second "negative dilute" test result, I will not be considered for employment. I understand that some of employer's Clients have adopted different policies requiring drug and/or alcohol testing. It is my understanding that the Policy and Client policies are implemented for the purpose of providing me with a safer work environment. I voluntarily consent to be tested for evidence of the presence of controlled substances and/or alcohol in my body through the analysis of my urine, breath and/or blood. I also authorize and consent to the release of the results of such drug and/or alcohol tests to employees, agents and representatives of employer, the Client, and the drug testing companies (including the testing laboratory). In consideration for my employment and/or my continued employment, I hereby release employer, its Clients, the drug testing laboratory or any facility and their representatives that perform the testing, from any and all liability and responsibility arising out of or relating to the performance of any drug test and/or alcohol test (during my assignment) required by the Policy and Client policy and Client policies and/or any employment related decisions made by employer or its Clients based on any information obtained from a drug/alcohol test. I hereby authorize employer to transmit, electronically or otherwise any information necessary to perform drug screening including all or part of my social security number where permitted by law. I have read and understand the above. I acknowledge that a photocopy or facsimile copy of this signed consent and authorization be accepted with the same authority as the original. This release is valid for all private persons and entities, and federal, state, county and local agencies and authorities. Signature: _ SSN: --------------------------------
AUTHORIZATION FOR BACKGROUND INVESTIGATION In connection with my application for employment or promotion or other job change, I understand that employer may obtain an INVESTIGATIVE CONSUMER REPORT (Background Check) that will include information as to my character, general reputation, personal characteristics and mode of living. This report may reveal information about work habits, including oral assessments of my job performance, experiences and abilities, along with reasons for termination of past employment. I authorize and request any present or former employer, school, police department, court records, including those maintained by both public and private organizations, financial institution or other persons having personal knowledge about me to furnish ANY employer Agency and/or its' agents with any and all information in their possession regarding me for the purpose of confirming the information contained on my Application and/or obtaining other information which may be material to my qualifications for employment. I am willing that a photocopy of this authorization be accepted with the same authority as the original, and I specifically waive any written notice from any present or former employer who may provide information based upon this authorization request. The following is my true and complete legal name and all information is true and correct to the best of my knowledge: Print Full Name: Print Maiden Name or Other Names Used: City: State: Zip Code: List all addresses that you have lived at in the past seven (7) years: (Use additional paper if needed) : City: State: Zip Code: _ Date of Birth: / / Social Security Number: Driver's License Number: - State: -- - Exp. Date: ----- Applicant Signature: Date: / / _
Please initial next to the number. POLICIES AND PROCEDURES CHECKLIST 1. I understand employer takes its responsibility as my employer very seriously, and that it has gone to great length to provide a safe work environment. I am injured on the job, I will report the injury immediately to an employer's representative and will need to submit to a drug screen or alcohol test after any injury associated or related to my assignment. I am aware that employer has workers compensation insurance that will pay medical expenses and wage on legitimate claims. I also understand that employer has extensive experience investigating claims and will fight fraudulent claims with all available resources. 2. If I sustain an injury on the job, I will inform the client and employer immediately who will coordinate with the client and me the proper procedures for treatment and reporting of the accident. 3. Employer has a strict "Substance Abuse Policy", and I have signed a consent form to submit to drug testing. I understand that my failure to comply with this agreement will be grounds for my immediate termination. 4. I understand and will comply with employer safety rules and regulations and hazardous communication program explained to me in employer's orientation. I will always be safety cautious and wear proper safety attire according to the assignment. 5. I am telephone accessible and I have reliable transportation. 6. I understand that I am an employee of employer and only employer or I can terminate my employment. When an assignment ends I must report to employer for my next job assignment. Failure to do so or to accept my next job assignment will indicate that I have voluntarily quit and may not be eligible for unemployment benefits. 7. I understand that I am expected to complete any job assignment I accept. I understand that if I do not complete or promptly notify of my inability to complete the assignment, or if I do not report for my assignment then employer may assume I have voluntarily quit, and I may not be eligible for unemployment benefits. 8. If for some unexpected reason, such as an emergency or illness, I cannot make it to work or will be late, I will contact employer as soon as possible but no later than 2 hours prior to the start of my shift. 9. I understand employer's requirements for receiving information documenting hours worked, the method of providing this information, and the time frame for me to provide this information. I understand employer will not recognize or pay for any hours worked by an employee without proper documentation verifying hours worked. If required to turn in your own timecard, please turn in your timecard no later than Monday by noon. If turned in late this will cause delay on your payroll. 10. I have read and fully understand the above statements regarding employer s policies and procedures and agree to the same. I understand that failure to comply with these policies and procedures could lead to my termination and may jeopardize employment. 11. Always arrive 15min. before or on time for an interview or an assignment. 12. Please do not use company/client company telephones, computers or internet for personal use. 13. Please do not use cell phones, beepers, video equipment or audio headphones during work hours. All E q u i p m e n t should be turned off during work hours. Failure to comply may lead to further disciplinary action up to and including the ending of your assignment and/or termination from employer. 14. Payday is every Friday between 8am- 5pm. For your protection employer requires a picture ID to be presented at the time of picking up check. Applicant Signature Employer s Representative Signature Date Date
SAFETY POLICY The following safety policies must be followed by all employees on assignment at the Client's work-site: 1. Always adhere to all safety rules, regulations, and instructions at the job site where you are working. Familiarize yourself and comply with all warning signs. 2. No employee will work in any situation or environment where the work may be considered hazardous or dangerous. If you have any doubt that you are not working in a safe environment, immediately consult your supervisor on the job or call the Branch immediately. 3. Do not begin working on a new job assignment without having been trained on the proper safety orientation about your area and about any machinery that you might be expected to use during the course of your assignment. 4. DO NOT operate a piece of equipment or machinery without prior approval from your employer's representative. 5. All defective machinery or equipment must be reported to your supervisor and employer's representative. 6. If you are involved in repairing or cleaning machinery, be sure that the main source of power has been turned off and properly tagged to conform with all safety procedures. 7. The job site supervisor is responsible for informing you of any additionally required Personal Protective Equipment or P.P.E. (goggles, gloves, etc.) needed at that workstation. 8. Work behavior that is not professional in conduct, such as horseplay, pranks, or throwing debris at a person or object, is forbidden at all times at the work site. 9. Keep out from under suspended loads. 10. All employees are expected and required to keep their work area clean and orderly. 11. Appropriate clothing and footwear must be worn on the job at all times. 12. Always use the correct tools for the job. If unsure which tool to use ask the job supervisor. Never use a defective tool. 13. Never walk across, crawl, or reach under or into, any moving chains or conveyors, or in the pathway of operating equipment. 14. Do not perform maintenance or clean up in or around any chains or conveyors, or in the pathway of operating equipment. 15. Never put your hands, feet, or any part of your body into operating machinery. 16. Immediately report all accidents to your supervisor. Remember to identify yourself as an employee. You will have to fill out an Accident Report. 17. Report any on-the-job accident to the employer's Branch office as soon as possible. 18. Should you incur any injuries while on the job, contact the employer's Branch office immediately. It is your responsibility to contact us as well as to notify the work-site supervisor as soon as the injury occurs. 19. Remember, if you don't know, or if you are in doubt, ask your supervisor and/or call the employer's Branch office. 20. If you require assistance when lifting an object, please ask a co-worker for assistance. Remember; lift with your legs not your back. Do not under any circumstances lift more than 50 pounds. Your safety is our concern. We want each and every employee to have a perfect safety record. Failure to comply with these guidelines may result in disciplinary action up to and including suspension and/or termination. Employer also reserves the right to terminate any employee for complete negligence and disregard for safety. If an employee is injured on-the-job because due to negligence, he/she can be reprimanded and/or terminated from employer, it s Client and any future assignments with employer. I UNDERSTAND AND WILL COMPLY WITH THE GUIDELINES LISTED ABOVE. EMPLOYEE PRINT NAME SIGNATURE DATE "SAFETY IS OUR TOP PRIORITY!"
Date: - Score: --- /8 correct SAFETY ORIENTATION QUIZ Circle One 1. TRUE or FALSE you can use Drugs and Alcohol if your supervisor said it was O.K. 2. TRUE or FALSE you should inspect your work area for any unsafe conditions BEFORE you start work and after all breaks. 3. TRUE or FALSE when used correctly, Personal Protective Equipment will help prevent injuries and can save your life. 4. TRUE or FALSE safety glasses only need to be worn when you remember to bring them to work. 5. TRUE or FALSE when repairing any type of equipment, you must ALWAYS be sure to turn it off and unplug the machine BEFORE you begin to repair it. 6. Being careless at work can cause (a.) Injuries (b.) Accidents (c.) Toothaches (d.) Both A&B 7. When you are concentrating on your job assignment you: i. Are more likely to make a mistake ii. Will impair your judgment and cause an accident iii. Reduce a chance of an accident and an injury 8. If you come across an unsafe work are, you should: i. Continue to work and wait for someone else to report it. ii. Leave your work assignment and comeback the next day to see if it has been fixed iii. Report it immediately to your Supervisor and/or the Safety Director All applicants mu.st have a minimum of 6 correct answers in order to be considered for employment. If you do not receive a score of 6 or higher, you will be able to re-view the "Safety Orientation" video again and retake the quiz. If atthat time you do not pass with a score of 6 or greater, you will not be considered for employment at this time. You will be able to reapply 3 months from now.
PROHIBITION OF HARASSMENT 1. Policy Statement Employer strictly prohibits unlawful harassment. This includes harassment on the basis of pregnancy, childbirth or related medical condition, age, marital status, sex, sexual orientation, race, color, ancestry, national origin, citizenship, religion, creed, physical disability, mental disability, medical condition, or any other protected class under applicable law. 2. Harassment Defined A. Harassment may consist of offensive verbal, physical, or visual conduct when such conduct is based on or related to an individual's sex and/or membership in one of the above-described protected classifications, and: (1) Submission to the offensive conduct is an explicit or implicit term or condition of employment; (2) Submission to or rejection of the offensive conduct forms the basis for an employment decision affecting the employee; or (3) The offensive conduct has the purpose or effect of unreasonably interfering with an individual's work performance or creates and intimidating, hostile, or offensive working environment. B. Examples of what may constitute prohibited harassment include, but are not limited to, the following: (1) Kidding or joking about sex or membership in one of the protected classifications; (2) Hugs, pats, and similar physical contact; (3) Assault, impeding or blocking movement, or any physical interference with normal work or movement; (4) Cartoons, posters, and other materials referring to sex or membership in one of the protected classifications; (5) Threats/bribes intended to induce sexual favors; (6) Continued suggestions or invitations to social events outside the workplace after being told such suggestions are unwelcome; (7) Degrading words or offensive terms of a sexual nature based on the individual's membership in one of the protected classifications; (8) Prolonged staring or leering at a person; (9) Similar conduct directed at an individual on the basis of race, color, ancestry, religious creed, handicap or disability, medical condition, age, marital status, sexual orientation, or any other protected classification under applicable law. 3. Internal Reporting Procedure Any associate who believes that he or she has been the victim of sexual or other prohibited harassment should immediately notify his/her Supervisor. We will investigate all such claims and take appropriate corrective action. I have read and understood the prohibition of harassment policy. Print Name: Signature: Date:
Payday ALL PAYCHECKS WILL BE HELD IN THE OFFICE UNLESS OTHERWISE SPECIFIED. YOU MAY PICK UP YOUR PAYCHECK ON FRIDAY'S. CHECKS CAN NEVER BE PICKED UP EARLY FOR ANY REASON. IF YOU WOULD LIKE YOUR CHECKS MAILED, PLEASE CALL DIRECT HIRE STAFFING BEFORE THURSDAY. IF MAILED, PLEASE DOUBLE CHECK YOUR ADDRESS ON YOUR APPLICATION TO ENSURE YOUR PAYCHECK GOES TO THE CORRECT LOCATION. DIRECT HIRE STAFFING CANNOT GUARANTEE THE DELIVERY DATE OF YOUR CHECK. IF YOU FEEL YOUR CHECK IS LOST, YOU MAY REQUEST A STOP PAYMENT. THE $32.00 BANK FEE IS PASSED ON TO YOU. DIRECT HIRE STAFFING WILL DEDUCT $32.00 FROM THE REPLACEMENT CHECK AND REISSUE YOU PAYCHECK. IF YOU DO RECEIVE YOUR "LOST CHECK" AFTER A REPLACEMENT HAS BEEN ISSUED, PLEASE LET A DIRECT HIRE STAFFING REPRESENTATIVE KNOW IMMEDIATELY. THE "LOST CHECK" WILL NOT BE CASHABLE. By signing below you acknowledge that you accept and understand the procedures explained above. Signature: Date:
UNEMPLOYMENT Please carefully read the below paragraphs. Please sign and date acknowledging that you have read, understand and have been provided a copy of this form. An applicant who, within five calendar days after completion of suitable temporary job assignment from a staffing service employer: 1. Fails without good cause to affirmatively request an additional job assignment or (2) refuses without good cause an additional suitable job assignment offered shall be considered to have quit employment. This paragraph shall apply only if, at the time of commencement of employment with the staffing service employer, the applicant signed and was provided a copy of a separate document written in clear and concise language that informed the applicant of this paragraph, For purposes of this paragraph, "good cause" shall be a reason that is significant and would compel an average (1) reasonable worker, who would otherwise want an additional temporary job assignment with the staffing service employer, (1) to fail to contact the staffing service employer, or (2) to refuse an offered assignment. Employee Signature Date Printed Name