APPLICATION FOR EMPLOYMENT V4

APPLICATION FOR EMPLOYMENT
WE ARE AN EQUAL OPPORTUNITY EMPLOYER

We consider applicants for all positions without regard to age, race, religious creed, color, national origin, ancestry, physical disability, mental disability, medical condition, marital status, sexual orientation, or sex of any person or any other legally protected status pursuant to California’s Fair Employment Practices and Housing Act, California Labor Code and other relevant federal, state, and local laws. Any applicant employed by Diligent Staffing Inc. is employed at the will of the employer.
APPLICANT CONTACT INFORMATION
Email*
example@example.com
Name*

First NameMiddle NameLast Name
Phone Number*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Date of Application*

MonthDayYear
Date
Social Security Number
SSN
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Birthday*

MonthDayYear
Date
Gender*

MaleFemaleRather not sayOther
Photo of your ID card*

Make sure that the characters in the photo are clear and recognizable. Supported formats: JPG and PNG. Maximum file size: 2 MB
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Employment Experience
Start with your present or last job. Fill out a complete section for the last/present job. Include any job-related military service assignments and volunteer activities.
Employer & Address*

Street Address

Street Address Line 2

CityState

Zip Code
Name of immediate supervisor*

First NameLast Name
Supervisor phone number*
Please enter a valid phone number.
Work Performed*
Dates Employed:
From Date* to Date*
Wage / Salary:
Starting Initial: * Final: *
What is your best guess as to how this supervisor would rate your overall performance?*

1

2

3

4

5

1 is Worst, 5 is Best
What did you like most about your job?*
What do you like least about your job?*
Reason for Leaving

Terms and Conditions

1.-Employer of Record. I acknowledge that my employer of record for my initial job assignment and any subsequent assignments is Diligent Staffing Inc. As such the applicable terms and conditions of this original job application should apply to my initial assignment as well as any subsequent assignments unless changed and/ or modified by Diligent Staffing Inc. in writing. In the event that any of the terms and conditions of this job application is deemed to be unenforceable such determination will not void the validity of any other provision and this shall be adjusted so as to reflect the intent of said provisions to the greatest extent possible.

2.- Termination of Employment. As an employee of Diligent Staffing Inc., I agree to comply with all Diligent Staffing Inc's regulations and understand that my employment with Diligent Staffing Inc. may be terminated at any time by me or Diligent Staffing Inc. with or without notice for any reason. I also understand that job abandonment with or without notice is subject to immediate termination I also understand that in order to be considered for temporary job assignments I MUST register my availability for work with Diligent Staffing Inc. on a daily basis and that failing to do so may affect my eligibility for unemployment compensation. Likewise, I understand that registering my availability for work does not constitute employment; that I am not employed until I actually begin working on a job assignment, and that my employment with Diligent Staffing Inc. is TERMINATED at the end of each day.

3.- Safety. As an Employee of Diligent Staffing Inc. I am aware I must wear and/or use ALL safety equipment provided to me by either Diligent Staffing Inc., its customers or self owned, for the performance of any job assignment. I understand that failure to do so can result in the immediate termination of my employment with Diligent Staffing Inc. or the temporary suspension from any current job assignments at the sole discretion of Diligent Staffing Inc. I am aware I am required to contact my immediate supervisor and Diligent Staffing Inc. if I believe the job assignment is unsafe. I also understand that in the event I suffer a WORK-RELATED injury or illness while at a job assignment I MUST immediately report the injury or illness to my direct supervisor and Diligent Staffing Inc. in order to obtain the required Diligent Staffing Inc. authorization to receive medical attention. Furthermore I understand that unless emergency treatment is required as a result of a work related injury or illness, in which case 911 should be contacted immediately, all work related injuries will be treated at the designated Medical Network Provider facilities of Diligent Staffing Inc Choice.

I agree to NOT hold Diligent Staffing Inc, it’s officers and employees harmless for any penalties, fines, and work related injuries during my employment with Diligent Staffing Inc. Furthermore, I understand that except where limited or prohibited by law, in the event I suffer a job related injury or illness I will be tested for the presence of drugs and/or alcohol in accordance with acceptable medical procedures. I am aware that, subject to applicable law, refusing to submit to testing may subject me to dismissal. I therefore agree to hold harmless Diligent Staffing Inc. its principals, agents, employees and clients for any and all consequences arising from my testing positive for the use and/or influence of drugs and/or alcohol at the time of my injury or illness.

Therefore, I agree that in the event I am injured or become ill while working for Diligent Staffing Inc. I will look only to Diligent Staffing Inc. Workers’ Compensation coverage and not to its customer for any recovery. For myself and on behalf of my heirs, executor, personal representatives and assigns, I waive, release and forever discharge any claim that I may now have or that may later accrue against any customer of Diligent Staffing Inc. which directly or indirectly results from any injuries which may occur to me while on a temporary work assignment for Diligent Staffing Inc. I further elect and agree that the only remedy for any injury or illness sustained while working for Diligent Staffing Inc. and its customer is exclusively the Workers’ Compensation coverage provided by Diligent Staffing Inc. I understand I am not waiving or releasing any claims which I may have against the Workers’ Compensation coverage provided by Diligent Staffing Inc.

4.-Drug Testing. As an employee of Diligent Staffing Inc. I agree to be drug tested when required by a job assignment if I wish to be considered for said assignments. I agree that by consenting to be drug tested I am also consenting for the result of such test to be shared with Diligent Staffing Inc. customers. I understand that a positive drug test can, at the sole discretion of Diligent Staffing Inc. result in the immediate termination of my employment with Diligent Staffing Inc.

5.-Workplace Conduct. As an employee of Diligent Staffing Inc. I understand that I am expected to conduct myself in a professional manner at all times while on a job assignment. I am aware common courtesy and respectful behavior towards co-workers and management staff is the norm. Furthermore I understand the use of profanity, abusive and derogatory language, theft and/or fraud, property damage, harassment, fighting, tardiness and poor performance will, upon the sole discretion of Diligent Staffing Inc. result in my temporal suspension or the termination of my employment.

6.- Fringe Benefits. I understand that my employment with Diligent Staffing Inc. does not include fringe benefits of any type.

7.- Dispute Resolution. Diligent Staffing Inc. and I agree that in the event of any claims resulting from or in relation with this Employment Agreement, including but not limited to its breach, my application, termination of employment, alleged violations of constitutional rights, federal, state or local laws will be resolved by binding arbitration under the

Federal Arbitration Act and be administered by the American Arbitration Association under the Employment Arbitration Rules in effect at the time of the arbitration. In the event that Arbitration is not enforceable, Diligent Staffing Inc. and I, agree to present our claims for resolution by a bench trial (trial by judge.)

8.- Representative Actions or Actions on Behalf of Others. I agree that in order to be represented by others in a law suit against Diligent Staffing Inc. my written consent must be first obtained by the representing party. Likewise I agree not to represent anyone else without first securing their writing permission.

9.- Diligent Staffing Inc and I agree that in the event of any claims resulting from or in relation with this Employment Agreement, including but not limited to its breach, my application, termination of employment, alleged violations of constitutional rights, federal, state or local laws, shall be processed with proper authorities within thirty (30) days from the date of the incident.

10.- Commuting. As an employee of Diligent Staffing Inc, I agree that is my sole responsibility to secure the proper means of transportation, be either public or private, to the job location of my assignment.

11.- Release of employment records authorization. I agree that by completing this job application I am authorizing Diligent Staffing Inc to keep certain records related to my employment including but not limited to this application, I-9 forms and any drug test results, and to release, upon request, these records to third parties such as Diligent Staffing Inc customers. By completing this application I am also authorizing Diligent Staffing Inc to contact my present and past employers for the purpose of confirming my past employment history including but no limited to, length of employment, wages and performance.
Initials*
I agree to release and indemnify and release Diligent Staffing Inc, it’s officers and employees harmless for any penalties, fines, and work related injuries during my employment with Diligent Staffing Inc*

First NameLast Name
Signature of Applicant*

Clear

Applicant's Statement

I certify that the answers given herein are true and complete to the best of knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge.
I understand, also, that I am required to abide by all rules and regulations of the employer.*

First NameLast Name
Signature of Applicant*

Clear

STATEMENT AND ACKNOWLEDGEMENT OF AT-WILL EMPLOYMENT

As an employee of Diligent Staffing Inc., your employment has been and continues to be “atwill.” This means that during the course of employment with the Company, employees are free to terminate their employment with the Company at any time, with or without a reason, and the Company has the right to terminate employees at any time, with or without a reason. Although the Company may choose to terminate an employee for cause, cause is not required.

No one other than the President of the Company has the authority to alter this at-will employment arrangement, to enter into an agreement for employment for a specified period of time, or to make any agreement contrary to this at-will arrangement. Furthermore, any such agreement must be in writing and must be signed by the President of the Company.

By signing in the space provided below, you hereby acknowledge that you have been given a copy of the Company’s Statement and Acknowledgment of At-Will Employment, that you have read the Statement and that you understand its contents, and that you further understand that the Statement supersedes any and all previous agreements, policies, practices or guidelines, whether oral or written.
Applicant Name*

First NameLast Name
Signature of Applicant*

Clear
Note to Employee: The original of this form will go into your personnel file.

EMERGENCY CONTACT INFORMATION

Please complete the following information to ensure we maintain a current record of contact information for you and your emergency contacts.
Emergency Contact Information
Contact Name

First NameLast Name
Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Primary Phone
Please enter a valid phone number.
Contact Alternate Phone
Please enter a valid phone number.
Relationship
Should be Empty:

APPLICATION FOR EMPLOYMENT

WE ARE AN EQUAL OPPORTUNITY EMPLOYER

APPLICANT CONTACT INFORMATION

APPLICANT BACKGROUND

Employment Experience

Terms and Conditions

Applicant's Statement

STATEMENT AND ACKNOWLEDGEMENT OF AT-WILL EMPLOYMENT

EMERGENCY CONTACT INFORMATION

Emergency Contact Information