EMPLOYMENT APPLICATION

Step 1 of 7

PREVIOUS EMPLOYMENT
Please list most recent positions first.
Date
From:
MM slash DD slash YYYY
Date
To:
MM slash DD slash YYYY
Name of Employer
Company Name:
Address of Employer
Street Address City State / Province / Region ZIP / Postal Code
Hidden
Rate of Pay
Start:
Hidden
Rate of Pay
Finish:
Supervisor 1
Name & Title
Supervisor's Phone Number
Telephone
Supervisor 2
Name & Title
Supervisor's Phone Number
Telephone
Reason for Leaving
May we contact employer?
- YES
- NO
Last Title & Duties
Date
From:
MM slash DD slash YYYY
Date
To:
MM slash DD slash YYYY
Name of Employer
Company Name:
Address of Employer
Street Address City State / Province / Region ZIP / Postal Code
Hidden
Rate of Pay
Start:
Hidden
Rate of Pay
Finish:
Supervisor 1
Name & Title
Supervisor's Phone Number
Telephone
Supervisor 2
Name & Title
Supervisor's Phone Number
Telephone
Reason for Leaving
May we contact employer?
- YES
- NO
Last Title & Duties
Date
From:
MM slash DD slash YYYY
Date
To:
MM slash DD slash YYYY
Name of Employer
Company Name:
Address of Employer
Street Address City State / Province / Region ZIP / Postal Code
Hidden
Rate of Pay
Start:
Hidden
Rate of Pay
Finish:
Supervisor 1
Name & Title
Supervisor's Phone Number
Telephone
Supervisor 2
Name & Title
Supervisor's Phone Number
Telephone
Reason for Leaving
May we contact employer?
- YES
- NO
Last Title & Duties

PLEASE LIST THREE (3) PROFESSIONAL REFERENCES
Name
Full Name Relationship
Company Name
Name Phone
Address
Name
Full Name Relationship
Company Name
Name Phone
Address
Name
Full Name Relationship
Company Name
Name Phone
Address

For each of the following I circles “YES” to, I will be given written disclosure forms for signature prior to the start of any assignment requiring pre-employment drug test, background checks, credit checks or DMV records. I understand that if I circle “NO” to pre-employment drug testing, background checks, credit checks or DMV records, this will not preclude me from contract, contract to hire or direct hire assignments where pre-employment drug testing, background checks, credit checks or DMV records are not required.
wish to be considered for an assignment where pre-employment drug testing is required.
- YES, I do
- NO, I do not
wish to be considered for an assignment where pre-employment drug testing is required.
wish to be considered for an assignment where background checks are required.
- YES, I do
- NO, I do not
wish to be considered for an assignment where background checks are required.
wish to be considered for an assignment where DMV records are required.
- YES, I do
- NO, I do not
wish to be considered for an assignment where DMV records are required.
I hereby authorize the Emerald Group, Inc., dba Emerald Staffing, Inc. to make such investigations and inquiries into my employment, educational history and other related matters, as may be necessary in arriving at an employment decision. I HEREBY release employers, schools, and other persons from all liability in responding to inquiries connected with my application and for employment and I specifically authorize the release of information by any schools, individuals, services, and other entities. I HEREBY AFFIRM: That all information given by me on this pre-employment application and this employee data and work history card is true and complete. If my answers are false or misleading, you have the right to dismiss me immediately. If selected for employment, I agree to provide documentation showing I am authorized to work in the United States of America. You may contact my former employers for references and release the information herein to your clients and insurance company. In the event of an “on the job” injury, I will submit to a post accident drug test. I will notify you when the assignment is ending and my availability for work.

IF I DO NOT NOTIFY EMERALD OF THIS INFORMATION THE ASSUMPTION MADE BY EMERALD IS: I AM NO LONGER AVAILABLE FOR WORK AND THEREFORE QUIT EMERALD.
Applicant Name
(Please print)
First & Last Name
Applicant Signature
Name Date

EMPLOYMENT APPLICATION

Step 1 of 7

PERSONAL

EDUCATION

PREVIOUS EMPLOYMENT

WHAT OTHER COMPANIES ARE YOU INTERVIEWING WITH?

PLEASE LIST THREE (3) PROFESSIONAL REFERENCES

SKILL CHECKLIST