Employment Application: QR Card

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?

How did you learn about this job position?

Who referred you?

They must be a current employee.

Have you ever worked for Rexius or its affiliates before?

If yes, please give dates of employment, location, and job title.

Have you ever applied for work with Rexius or its affiliates before?

If yes, please give date, location, and job for which you applied.

Available Start Date

Date

Name

First NameMiddle NameLast Name

Address

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Phone Type

Alternate Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Phone Type

Email Address

example@example.com

Preferred Contact Method

Are you at least 18 years of Age?

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

Please list any currently valid and special motor vehicle, operator licenses or trade/craft certifications you hold.

Please check your highest level of education:

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?

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

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

Format: (000) 000-0000.

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.

2. Name of Employer

Location

Phone number

Format: (000) 000-0000.

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.

3. Name of Employer

Location

Phone number

Format: (000) 000-0000.

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

Please check ALL that apply to or describe your physical capabilities

Please check only one from the options below

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?

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?

*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.)

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.)

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?

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.