Employment Application

First Name Last Name

Street Address

City State Zipcode

Birthdate (xx/xx/xx)

Are You 18 or Older: Yes No

Home Phone Cell Phone

Are you willing to take pre-employment drug screens for job assignments for customers who require them? Yes No

Date I am Available

Type of Work Preferred

Length of Assignments You Prefer: Short-Term Long-Term

In Case of Emergency Contact Phone

How Did You Hear About Us?

Employee's Name

Do You Smoke? Yes No

If you smoke, can you refrain from smoking during an 8-10 hour assignment including breaks and lunch due to assignment company's policy? Yes No

Locations in Metro Area Willing to Work

How many pounds of steady lifting can you handle (if applicable for the type of work for which you are applying? 0 20 40 60