Workonomics Staffing Resource

Personal Information

Name *

First Last

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Home Number *

### - ### - ####

Cell Number *

### - ### - ####

Date of Birth *

E-mail Address *

Social Security *

Driver's License Number/ State/Expiration *

EMPLOYMENT DESIRED:

List below all present and past employers over the past ten years, starting with your most recent employer. Account for all periods of unemployment. You must complete this section even if attaching a resume.

May We Contact Your Present Employer? *

Yes

No

Position Applied For *

Days Available *

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Any

Hours Available *

AM

PM

Graveyard

For specific Day/Hour availability, please enter information below.

Desired Duration: *

Temp

Temp-Hire

Direct Hire

Check all that apply

What date are you available to start work? *

MM / DD / YYYY

EDUCATION:

Name and Address Of School - Degree/Diploma - Graduation Date *

Skills and Qualifications: Licenses, Skills, Training, Awards *

List any seminars, classes or other education not listed above which may help qualify you for this position:

EMPLOYMENT HISTORY:

Present Or Last Position:

Employer: *

Address: *

Supervisor: *

Phone Number *

### - ### - ####

Email

Position Title: *

Start Date *

MM / DD / YYYY

End Date *

MM / DD / YYYY

Responsibilities: *

Salary *

Input hourly wage, if not salaried.

Reason for Leaving: *

Did you acquire this job through a staffing / temp agency? *

Yes

No

If yes, list agency:

Previous Position

Employer:

Address:

Supervisor:

Phone Number

### - ### - ####

Email

Position Title:

Start Date

MM / DD / YYYY

End Date

MM / DD / YYYY

Responsibilities:

Salary

Input hourly wage, if not salaried.

Reason for Leaving:

Did you acquire this job through a staffing / temp agency?

Yes

No

If yes, list agency:

Additional Information:

List any languages other than English that you can speak, read or write that could be of benefit to the position applied for

Identify formal job training that relates to the position your applying for:

Identify what skills or certification you possess related to this position:

Additional Information:

Have you ever registered or been employed with this agency before?

Yes

No

If Yes, When?

If you are under 18 years of age, can you provide proof of your eligibility to work?

Yes

No

If hired, can you provide proof of U.S. citizenship or proof of your legal right to work in the U.S.?

Yes

No

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?

Yes

No

If Yes, please explain:

If driving is a requirement of the position applied for, have you in the last 7 years been convicted of Driving Under the Influence “(DUI)”

Yes

No

If hired, do you have a reliable means of transportation to and from work?

Yes

No

If hired, would you be able to travel or work overtime as needed?

Yes

No

Have you ever been convicted of a felony or misdemeanor?

Yes

No

If Yes, please explain:

References:

Name/Title/Company/Address/Phone/E-Mail/Relationship

List 2 References then 1 Emergency Contact

I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.

Do you agree with the terms and conditions? *

Yes, I agree.

Initial *

Date *

MM / DD / YYYY

Upload Resume (PDF or Word Doc)