Language
English (US)
Branch
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Santa Ana
Garden Grove
Los Angeles County
Inland Empire
San Gabriel Valley
Date/Fecha
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/
Month
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Day
Year
Date
Social Sec. Num:
Last Name/Apellido:
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First Name/Primer Nombre:
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Address/Domicilio
Street Address
Apt
City
State / Province
Postal / Zip Code
DOB/Fecha de Nacimiento:
*
Phone Number/ Telefono: By providing your phone number, you agree to receive text messages and autodialed calls (including prerecorded messages) at that number. If you opt-out, we will send you a text message to confirm we have processed your cancellation.
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(###) ###-####
Emergency Contact/Contacto de Emergencia:
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Emergency Phone Number/Numero de Emergencia
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(###) ###-####
Work History/ Historial de Trabajo
Company/Compania:
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Phone Number/Telefono
-
Area Code (###)
Phone Number (###-####)
Position/Posicion:
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Address (city)/Domicilio (cuidad)
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Supervisor
Reason for Leaving/Razon por Irse?
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Duties responsible for/Obligaciones del Trabajo:
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Date Started/Fecha de Comienzo
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-
Month
-
Day
Year
Date
End Date/Ultimo dia
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Month
-
Day
Year
Date
Company/Compania
Phone Number/ Telefono
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Area Code
Phone Number
City/Cuidad
Supervisor
Position/Posicion:
Reason for leaving/Razon por irse:
Duties responsible for/Obligaciones del Trabajo:
Dates Employed From/Fechas Trabajadas:
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Month
/
Day
Year
Date
To Date/ Ultimo Dia
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Month
-
Day
Year
Date
Company/Compania
Phone/Telefono:
Address/Domicilio:
Supervisor:
Position/Posicion:
Reason for leaving/Razon por irse:
Duties responsible for/Obligaciones del Trabajo:
Dates Employed From/Fechas Trabajadas:
/
Month
/
Day
Year
Date
To Date/ Ultimo Dia
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Month
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Day
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Date
Name/Nombre
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Signature/Firma
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Clear
Date/Fecha
*
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Month
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Day
Year
Date
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Heading
1.Can you Lift and/or carry up to 40 pounds "periodically" during your shift
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Yes
No
2. Can you Move about on foot as required
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Yes
No
3. Can you Extend your hands and arms away from your body and move them in all directions
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Yes
No
4. Can you Understand written and verbal instructions, to include safety information
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Yes
No
5. Can you Read instructions, match numbers or letters, and identify colors
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Yes
No
6.Can you Perform the same motion over and over again, such as continuous typing at a computer keyboard, labeling, folding especially movement of your wrists, hands, and/or fingers
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Yes
No
7. Can you Wear proper safety equipment (including, gloves, aprons, safety glasses/goggles, hard hats) In areas where such safety equipment is required
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Yes
No
8. Can you Wear dust masks in work areas where such safety equipment is required
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Yes
No
9.Can you Work effectively around moving mechanical parts and electric wires
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Yes
No
10. Can you use your hands to Move objects up and down, and back and forth
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Yes
No
11. Can you Pick up, pinch, type, or otherwise work, mainly with your fingers rather than with your whole hand or arm
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Yes
No
12. Can you Apply pressure to an object with your fingers and palm
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Yes
No
13.Can you Keep your balance to prevent falling when walking, standing, crouching or going up or down stairs with your hands and arms on railing
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Yes
No
14. Can you Bend your body downward and forward by bending at the waist (stooping)
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Yes
No
15. Can you Bend your legs at the knee to come to a rest on your knee or knees(kneeling).
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Yes
No
16. Can you Bend at the waist routinely
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Yes
No
17. Can you Stand/sit for long periods of the day, if necessary
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Yes
No
18. Can you Work effectively and perform job tasks in a sometimes noisy environment
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Yes
No
19. Do you have any condition that would have an effect on your ability to perform the duties of this position with or without reasonable accommodations?
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Yes
No
20. Do you have any back limitations that would prevent you from perform typical warehouse duties?
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Yes
No
21. Do you have any wrist limitations, including repetitive motion?
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Yes
No
22. Have you ever had an injury to your hands/wrists/arms?
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Yes
No
23. Have you ever had an injury to your back/neck/shoulders?
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Yes
No
24. Have you ever had an injury to your legs/ankles/feet?
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Yes
No
25. If you answered "yes" to question #22. #23. or #24. didthe injury/injuries require surgery?
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Yes
No
26. Do you have ANY health problems, or are you taking ANY medication that could affect our ability to perform normal job functions?
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Yes
No
27. Do you have ANY allergies that would restrict you from working in certain environments or performing certain job functions?
*
Yes
No
IF YOU ANSWERED YES TO (#19-27) PLEASE EXPLAIN BELOW:
Name
*
First Name
Last Name
Signature
*
Clear
Date
*
-
Month
-
Day
Year
Date
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Availability
I AM AVAILABLE TO WORK FULL TIME
I AM AVAILABLE TO WORK PART TIME
I AM AVAILABLE FOR PROJECTS
I AM AVAILABLE SAME DAY
I AM AVAILABLE ON WEEKENDS
I AM AVAILABLE OVERTIME
Date available to start:
*
-
Month
-
Day
Year
Date
Are you at least 18 years old?
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Yes
No
Do you have reliable transportation?
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Yes
No
Have you ever been terminated from a position?
*
Yes
No
Have you ever abandoned a position?
*
Yes
No
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Please mark the following if you have AT LEAST 3 MONTHS of experience:
ADMINISTRATION
CONSTRUCTION
MECHANIC
FOOD MANUFACTURER
FORKLIFT
MACHINE OPERATOR
MAINTENANCE
WELDING
PRODUCTION
WAREHOUSE
MANAGEMENT
HOSPITALITY
Employee EEO Self-Identification Form
Completion of this form is voluntary
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Last four digits of Social Security Number
Voluntary Self-Identification of Ethnicity, Race and Gender
Hispanicor Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American,or other Spanish culture or origin regardless of race.
White (Not Hispanic or Latino): A person having origins in any of theoriginal peoples of Europe, the Middle East or North Africa
Black or African American (Not Hispanic or Latino): A person havingorigins in any of the black racial groups of Africa
NativeHawaiian or Pacific Islander (Not Hispanic or Latino): A person having originsin any of the peoples of Hawaii, Guam, Samoa or other Pacific Islands.
Asian (Not Hispanic or Latino): A person having origins in any of theoriginal peoples of the Far East, Southeast Asia or the Indian Subcontinent,including, for example, Cambodia, China, India, Japan, Korea, Malaysia,Pakistan, the Philippine Islands, Thailand and Vietnam.
Native American or Alaska Native (Not Hispanic or Latino): A personhaving origins in any of the original peoples of North and South America(including Central America) and who maintains tribal affiliation or communityattachment.
Two or more races (Not Hispanic or Latino): All persons who identify with more than one of the above five races.
SEX/GENDER CODE:
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Female
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I belong to the following classifications of protected Veterans
Disabled Veteran
Recently Separated Veteran
Active wartime or campaign badge Veteran
Armed Forces service medal Veteran
I am protected veteran, but choose not to self-identify the classification to which I belong
I am not a protected Veteran
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Last Name
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Please check one box below:
Yes, I have a disability
No, I do not have a disability
I do not wish to answer
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COVID STATUS ATTESTMANT
Please select the statement below that accurately describes your vaccination status:
*
I am fully vaccinated.
I received my second dose of the Pfizer or Moderna vaccine or my single dose of a Johnson & Johnson vaccine less thant wo weeks ago.
I received my first dose of Moderna or Pfizer, and my second appointment is scheduled.
I have not yet been vaccinated, but I have already scheduled an appointment to receive my first dose of vaccine.
I have NOT been vaccinated.
I decline to answer whether I have been vaccinated.
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