APPLICANT INFORMATION
Last Name
First
M.I.
Date of Birth
Street Address
Apartment/Unit#
City
State
Zip
Home Phone
Cell Phone
E-mail Address
Date Available
Social Security No.
Method of transportation to work
Shifts available to work
Are you a citizen of the United States?
YES NO
If no, are you authorized to work in the U.S.?
YES NO
Have you ever worked for this company?
YES NO
If so, when?
Have you ever been convicted of a felony or
been placed on probation?
YES NO
If yes, explain
Do you have any physical limitations?
YES NO
If yes, explain
EDUCATION
High School
Address
From
To
Did you graduate?
YES NO
College
Address
From
To
Did you graduate?
YES NO
Degree
Other
Address
From
To
Did you graduate?
YES NO
Degree
REFERENCES
Please list three professional references.
Full Name
Relationship
Company
Phone
Address
Full Name
Relationship
Company
Phone
Address
Full Name
Relationship
Company
Phone
Address
PREVIOUS EMPLOYMENT (BEGIN WITH MOST RECENT)
Company
Phone
Address
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference?
YES NO
Company
Phone
Address
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference?
YES NO
Company
Phone
Address
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference?
YES NO
EMERGENCY CONTACT INFORMATION
Name
Relationship
Phone #
Doctor to Notify
Phone #
Any medical considerations, allergies, etc.
AUTHORIZATION AND CONSENT
I hereby declare that all statements contained in this application are true and correct and understand that false or inaccurate information in the application will be a basis for termination. I hereby authorize TempCor to investigate my background and references, including a copy of this application to third party sources for the sole purpose of my placement on assignment. I understand that employment by TempCor is at will and that if employed, my employment will not be for any fixed period of time and may be terminated by TempCor at any time with or without cause. I also agree that I may be expected to work on a wide variety of job assignments in the area and agree to accept assignments for which I am qualified as they become available. I also understand my failure to report to any such assignment for work will indicate that I have quit. I also agree to submit to drug screens upon request or as specified in TempCor on their client's substance abuse policies.