Employment Application: QR Card

Employment Application
Rexius is an equal opportunity employer. Please complete this form fully, honestly and accurately. We appreciate your interest in employment with Rexius.
What position are you applying for?
Job Interest
How did you learn about this job position?*

Indeed.comCraigslist.comRexius.comCareerAmericaFacebookInstagramReferral
Who referred you?
They must be a current employee.
Have you ever worked for Rexius or its affiliates before?*

YesNo
If yes, please give dates of employment, location, and job title.*
Have you ever applied for work with Rexius or its affiliates before?*

YesNo
If yes, please give date, location, and job for which you applied.*
Personal Information
Available Start Date*

MonthDayYear
Date
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Phone Type

HomeCell
Alternate Phone Number
Please enter a valid phone number.
Phone Type

HomeCell
Email Address
example@example.com
Preferred Contact Method*

PhoneEmail
Are you at least 18 years of Age?*

YesNo
Can you, upon hiring, provide appropriate identification documenting and verifying your identity and your legal right to work in the USA?*

YesNo
Please list any currently valid and special motor vehicle, operator licenses or trade/craft certifications you hold.
Education and Training
Please check your highest level of education:*

NoneGEDHigh School DiplomaCertification(s)Associates DegreeBachelor's DegreeGraduate Degree
Work History
Please list your complete job history in order of occurance. Begin with your current or most recent job (if unemployed).
If presently employed, may we contact your current employer to verify employment?*

YesNoUnemployed/NA
If you have not yet had a job or are a student. Please check the box below.

Yes
If you have not yet had a job or are a student. Please list any relevant skills or experiences.*
1. Name of Employer*
Location*
Phone number*
Your Job Title / Responsibility*
Dates of employment:
Start and End Date (MM/YEAR)*
Supervisor’s Name*
Supervisor’s Title*
Reason for leaving (please be specific)*
You may comment on any other special qualifications you have related to this job or this company.
Have more job experience to enter? Check the box below.

Yes, I have more job experience to enter.
2. Name of Employer
Location
Phone number
Your Job Title /Responsibility
Dates of employment:
Start and End Date (MM/YEAR)
Supervisor’s Name
Supervisor’s Title
Reason for leaving (please be specific)
Have more job experience to enter? Check the box below.

Yes, I have more job history to enter.
3. Name of Employer
Location
Phone number
Your Job Title / Responsibility
Dates of employment:
Start and End Date (MM/YEAR)
Supervisor’s Name
Supervisor’s Title
Reason for leaving (please be specific)
Please explain any gaps greater than three months, in the above dates of employment (between one employer and another) / Explique cualquier brecha mayor a tres meses en las fechas de empleo anteriores (entre un empleador y otro) utilizando
Physical Capability Profile
Please check ALL that apply to or describe your physical capabilities

I can stand 8-10 hours per dayI can sit 8-10 hours per dayI can walk 8-10 hours per dayI can bend or reach 8-10 hours per dayI can twist or lift or reach 8-10 hours per day
Please check only one from the options below

I can lift, push, or pull up to 10 lbs on a regular basisI can lift, push, or pull up to 20 lbs on a regular basisI can lift, push, or pull up to 30 lbs on a regular basisI can lift, push, or pull up to 40 lbs on a regular basisI can lift, push, or pull more than 50 lbs on a regular basisI can lift, push, or pull more than 50 lbs on a regular basis
Job-Related Background
1. Regarding the job for which you have applied, are you familiar with this job and do you understand the basic physical requirements needed to perform it?*

YesNo
2. If yes, are you physically able to perform this job safely and without a significant risk of substantial harm to yourself or to others?*

YesNo
*Special Note/Section to Applicants with a Disability:
*You may answer “Yes” to question #2 above if you can perform all essential functions of the job with or without reasonable accommodation. The Company will provide reasonable accommodation to a person with a disability. However, you still are not required to identify yourself as a disabled person on this Application Form.
If you can perform the essential tasks of the job ONLY with an accommodation, then please respond to this question: How would you perform the tasks, and with what accommodations(s)?
Have you ever been counseled, warned or disciplined for an unsafe work practice or other safety violation in the past year? ( Note: A “Yes” answer may not necessarily bar you from employment here.)*

YesNo
If YES, please explain.
Have you ever had a “near miss” on the job where you nearly missed being injured or injuring someone else in the past year? ( Note: A “Yes” answer may not necessarily bar you from employment here.)*

YesNo
If YES, please explain.
Rexius believes that use of drugs or alcohol in the workplace is an unsafe work practice and creates increased risk to the consumer, fellow employees, customers and the public. Rexius is a Drug-Free and Alcohol-Free workplace. Use of illegal substances or abuse of controlled substances may result in disciplinary action or termination of employment.If employed, do you agree to abide by the Rexius Drug-Free and Alcohol-Free workplace standards?*

YesNo
Agreement and Release
PLEASE READ THE ENTIRE FOLLOWING SECTION HERE AND ON THE NEXT PAGE BEFORE SIGNING.

Then please sign this form at the bottom of the next page. Also, please initial each section in the center column indicating you have read that section.
WITH THIS APPLICATION BY MY SIGNATURE BELOW I AGREE TO ALL OF THE FOLLOWING TERMS:
Term, Condition, Expectation and/or Agreement

I certify that the information I have provided on this Application Form and on my Resume (if any) is true to the best of my knowledge.

Regarding this application, I understand that if the Company determines that I have made any false statements, answers or any misrepresentation or any omission of significant information, the Company is entitled to reject my Application, or if hired, to terminate my employment.
Initials*
Term, Condition, Expectation and/or Agreement

In the event I undergo a medical examination or evaluation as a part of the job placement process of the Company I agree to supply only information which is true to the best of my knowledge.

Regarding this examination or evaluation, I understand that if the Company determines that I have made any false oral or written statements or answers or any misrepresentation or any omission of significant information to the Company or to the physician or to his or her representative, the Company is entitled to terminate my conditional or actual employment at any time.
Initials*
Term, Condition, Expectation and/or Agreement

I authorize any person, school, current employer, past employer, physician or organization with knowledge of me or my work to provide the Company or its agent or representative with any information or opinion about me in response to an inquiry by the Company.

I release any such person, employer, physician or organization from any legal liability in making such statements or furnishing any and all information to the Company or to its representative or agent.
Initials*
Term, Condition, Expectation and/or Agreement

I authorize the Company or its agent or representative to check references regarding my employment and investigate any of the statements or answers provided by me on this Application or made to a physician or his or her representative (in the event of a medical examination or evaluation). The only exception to this authorization is where I have specifically requested in writing on this Application Form on the date below that no such inquiry be made.
Initials*
Term, Condition, Expectation and/or Agreement

I understand that my employment at this Company is on an “at will” (that is, mutual consent) basis. Therefore I agree that either I or the Company has the proper right to terminate my employment with or without cause at any time.
Initials*
I have read and understood, and I agree to this entire section above, entitled AGREEMENT & RELEASE.*

Clear
Alcohol and Drug Testing Consent Form
Rexius has requested that I take a drug/alcohol test under its Alcohol & Drug Policy as part of my application for employment. Accordingly, by my signature below, herby authorize Rexius, the Medical Review Officer and licensed laboratory selected by Rexius to perform a urinalysis on a urine specimen provided by me to test for drug use. I consent to this test and I also give my permission to the laboratory and Medical Review Officer to release the results of this drug test to Rexius. I agree that Rexius may use these results to determine my suitability for employment. If I am employed by Rexius I agree to any drug/alcohol testing the Company may require under its Alcohol and Drug Policy. If the laboratory finds the test invalid, and if the laboratory, Medical Review Officer or Rexius believe another test is appropriate, I agree to submit another specimen(s) for further testing. I understand that I will not be informed of the results of my pre-employment drug test unless I request it within 60 days of being notified of the disposition of my application. *

Clear
Should be Empty:

Employment Application

Job Interest

Personal Information

Education and Training

Work History

Physical Capability Profile

Job-Related Background

*Special Note/Section to Applicants with a Disability:

Agreement and Release

WITH THIS APPLICATION BY MY SIGNATURE BELOW I AGREE TO ALL OF THE FOLLOWING TERMS:

Alcohol and Drug Testing Consent Form