Name: Date:
Social Security:
Address:
City: State: Zip Code:
Phone Number(s) Home: Cell:
Position: (Warehouse, Clerical/Customer Service, Administrative, Labor)
Salary Desired:
Date You Can Start:
Are you currently employed? Yes No
If so, may we inquire of your present employer? Yes No
Have you ever applied to this company before? Yes No
If yes: Where? When?
Have you ever worked for a temporary staffing agency? Yes No
If yes: Where?
Have you ever been fired or asked to resign from a job? Yes No
Are you available to work same day assignments? Yes No
Are you willing to take a drug and alcohol screening today? Yes No
Have you ever been convicted of a crime (misdemeanor or felony)? Yes No
Please list any skills that may be beneficial to the type of work for which you are applying:
Company Name:
Supervisor Name:
Phone Number:
Dates of Employment: From: To:
Position Held: Salary:
Reason for leaving:
Please describe the type of work for which the candidate was responsible:
How would you describe the applicant’s relationship with coworkers and/or supervisors:
Excellent Good Fair Poor
Did the candidate have a positive ornegative work attitude?
How would you describe the quantity and quality of output generated by the former employee?
What were his or her strengths on the job?
What were his or her weaknesses on the job?
What is your overall assessment of this applicant?
Is this candidate eligible for rehire? YES NO
Electronic Signature: Date:
Terms of Agreement:I understand that this is not an application for employment.I certify that answers given herein are true and complete to the best of my knowledge.I authorize investigation of all statements contained in the pre-employment screen as may be necessary in arriving at an employment decision.I understand that I will not be considered for employment, unless my references are complete and comply with Divine Staffing’s standards.I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or with out cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.In the event of employment, I understand that false or misleading information given in my application, interview(s), may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.
I Agree I Disagree
