Name
*
First Name
Last Name
Have you ever been employed or attended school using any other name?
Yes
No
If yes, please explain:
Email Address
*
Primary Phone Number
*
(###)
###
####
Secondary Phone Number
(###)
###
####
Emergency Contact
*
Driver's License Number or State ID Number
Identification Issuing State
Street Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Do you have any employment restrictions resulting from a non-compete or confidentiality agreement?
Yes
No
Type of Work Desired
Education Staffing
Medical Staffing
Are you bilingual?
Yes
No
Foreign Language(s)
Are You Willing To Take A Drug Test Today?
*
Yes
No
History Of Criminal Convictions
*
Have you ever been arrested, convicted, plead guilty, or no contest, or forfeited bond or bail for any crime other than traffic violations?
Do you have military experience?
Yes
No
How did you hear about us?
When are you available to start?
Immediately
One - Two Weeks
Two - Three Weeks
Sixty - Ninety Days
Four Months or More
Not Sure At This Time
How many hours are you willing to work in a week?
Part-Time (20 Hours Max)
Full-Time (40 Hours Max)
What is the minimum pay you desire?
Do You Have Your Own Transportation?
*
Yes
No
Intend To Obtain Soon (30-60 Days)
How many miles are you willing to travel?
Are you a Student?
Yes
No
Will Start Attending School Soon (30-60 Days)
Name of Institution
Did You Graduate?
Yes
No
School Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Name of Institution
Did You Graduate?
Yes
No
College or Technical School Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Early Childhood Certification
Yes
No
In Progress
Company Name
*
Company Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Company Phone Number
*
(###)
###
####
Reason for Leaving
*
End Wage Hourly
*
May We Contact This Employer For A Reference Check?
*
Yes
No
Are you eligible for rehire?
Yes
No
Are There Any Additional Skills or Certifications You Would Like To Tell Us About?
- Software applications, Licenses, Certifications, etc.
- Positions of Leadership Held
- Honors / Awards / Scholarships
- Extracurricular Activities / Hobbies / Interests
Application Acknowledgement
*
I certify that I have answered the above questions truthfully and have not withheld any information
relative to this application. I understand that any falsification, misrepresentation, or omission, as well as
any misleading statements or omissions of the application information, attachments, and supporting
documents generally will result in denial of employment or immediate termination, if discovered after
hire.
I authorize Staffing Request, LLC to investigate whether I have a criminal record of
convictions, and, if so, the nature of such convictions and all the surrounding circumstances of the
conviction.
I understand that this application is not a contract, offer or promise of employment. By completing this
application I am expressing my genuine interest in working for Staffing Request, LLC . I
understand that an offer of employment may be subject to receipt of satisfactory reports and the
accuracy of all pre-employment information I have supplied. I acknowledge that if hired, my
employment with Staffing Request, LLC is on an at will basis. I am free to terminate my
employment Staffing Request, LLC at any time for any reason. Similarly, Staffing Request, LLC is free to terminate our employment relationship at any time, with or without
cause or advance notice. Acceptance of employment is not a contract for any specified time.
I understand and acknowledge that I am required to submit a physical examination, including a
tuberculosis screening. Additionally, I hereby authorize the release of the results of such an examination
to Staffing Request, LLC for their use in evaluating my suitability for employment. Further, I release the examining facility Staffing Request, LLC from any and all liability, and from any damage that may result in the release of such information.
I acknowledge reading and understand the forgoing statements.
Thank you for applying and your interest in joining the Staffing Request Family!
Once you have applied, please allow 48 hours for a representative to review your information and contact you based on your qualifications and experience.
If you have not received a phone call or email within 48 hours, please call us at 484.483.8496 to inquire.
