Online Application

Applicant Information:

Full name

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Number of years at this residence

Phone Number

Area Code Phone Number

Email

example@example.com

Emergency Contact

Contact name

First Name Last Name

Address

Street Address

Street Address Line 2

City State

Zip Code

Phone Number

Area Code Phone Number

Email

example@example.com

Job position applied for:

Who referred you to Premiere Staffing Services?

How will you get to work?

Are you willing to work any shift including nights and weekends?

Yes No

Overtime?

Yes No

When are you available to start work?

Date

Are you legally eligible to work in the U.S.?

Yes No

Are you able to perform the essential functions of the job position with or without reasonable accommodation?

Yes No

If no, please list accommodations required:

Level of education:

Certifications:

Employment History

*Not required if resume is provided

Employer Name

Supervisor Name

City, State, Zip

Job Duties:

Reasons for Leaving:

Last date of employment:

Date

Currently working

Employer Name

Supervisor Name

City, State, Zip

Job Duties:

Reasons for Leaving:

Last date of employment:

Date

Currently working

Certification

I certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be basis for rejection of my application, or if employment commences, immediate termination.

I authorize premiere Staffing Services to contact former employers and educational organizations to fully and freely communicate information regarding my previus employment, attdendance, and grades. I authorize those persons designated as references to fully and freely communicate information regarding my previus employment and education.

If an employment relationship is created, I understand that unlessI am offered a specific contract employment signed on behalf of the organization by its president, the employment relationship will be "at-will". In other word, the relatioship will be entirely voluntary in nature, and either I or my employer will be able to terminate my employment relationship at anytime without any cause. Moreover, no agent, representative, or employee of Premiere Staffing Services except in specific written contract of employment signed on behalf of the organization by its president, has the power to alter or vary the voluntary natureof the employment relationship.

I have carefully read the above certifications and I understand and agree to its terms.

Employment Application