| Date: |
September 4, 2010, 11:27 pm
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| Last Name: |
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| First Name: |
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| Middle Name: |
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| Maiden Name: |
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| Phone #: |
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| Cell #: |
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| Email: |
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| Social Security #: |
- - |
| Driver License #: |
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| State: |
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| Date of Birth: |
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| Shift Preference (check all that apply): 1st
2nd
3rd |
| Employment Desired (check all that apply):
Full Time
Part Time
Full or Part Time |
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Have you ever been convicted of a crime (including traffic/moving violations)?: Yes
No |
| If yes, explain each conviction(s), date of offense, designate misdemeanor or felony: |
Conviction 1: Date 1:
Conviction 2: Date 2:
Conviction 3: Date 3:
Conviction 4: Date 4:
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Address Information | Start with current address and go back 7 years: |
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Address 1: |
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From:
To:
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Address 2: |
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From:
To:
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Address 3: |
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From:
To:
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Address 4: |
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From:
To:
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| Is there any reason you can not perform the functions of the job?: Yes
No |
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Please check any of the following that you have experience with. |
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Work Experience
Please list your work experience for the past five years beginning with your most recent job held: |
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| Work Experience #1: |
(most recent) |
| Name of Employer: |
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| Street: |
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| City: |
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| State: |
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| Zip: |
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| Phone: |
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| Name of Supervisor: |
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| Employment Dates: |
From:
To:
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| Pay or Salary: |
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| Your Last Job Title: |
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| Reason for Leaving (be specific): |
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| May we contact this employer?: |
Yes
No |
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| Work Experience #2: |
(previous to #1) |
| Name of Employer: |
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| Street: |
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| City: |
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| State: |
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| Zip: |
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| Phone: |
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| Name of Supervisor: |
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| Employment Dates: |
From:
To:
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| Pay or Salary: |
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| Your Last Job Title: |
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| Reason for Leaving (be specific): |
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| May we contact this employer?: |
Yes
No |
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| Work Experience #3: |
(previous to #2) |
| Name of Employer: |
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| Street: |
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| City: |
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| State: |
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| Zip: |
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| Phone: |
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| Name of Supervisor: |
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| Employment Dates: |
From:
To:
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| Pay or Salary: |
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| Your Last Job Title: |
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| Reason for Leaving (be specific): |
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| May we contact this employer?: |
Yes
No |
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Statement of Acceptance:
I understand and agree that the acceptance of this application nor the subsequent entry into any type of employment relationship shall serve to create an actual or implied contract of employment, or otherwise to change in any respect the employment-at-will relationship between Accel and the undersigned, and that relationship cannot be altered except by a written instrument signed by the President of the Company. Both the undersigned and Accel may end the employment relationship at any time, without specified notice or reason.
I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contact.
In connection with my application for employment with Accel Temporary Services, LLC, I understand that, in connection with the routine processing of this employment application, the Company may request from a consumer reporting agency an investigative consumer report including information as to my credit worthiness, background, character, general reputation and personal characteristics. Upon written request from me, the Company, will provide me, within a reasonable period of time, with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act. I hereby authorize the report to be conducted, and authorize all persons, schools, companies, credit bureaus and law enforcement agencies, or the U.S. Military records custodian, to release information to Accel and/or its agents and contractors. I hereby release Accel, and all other individuals and entities from any and all liability.
I also understand that (1) the Company has a drug and alcohol policy that provides for pre-employment testing, as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment.
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| Legal Signature Confirmation (type your initials): |
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Type The Code You See Above
In All UPPER CASE Letters: |
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