Advanced Staffing Associates Employment Specialists Since 1987!

Advanced Staffing Associates

EMPLOYMENT APPLICATION

APPLICANT INFORMATION

* First Name:

Middle Name:

* Last Name:

Social Security:

Address:

City:

State:

Zip:

Date of Birth:

CONTACT INFORMATION

Home:

Cell:

* Email:

POSITION INFORMATION

Position Applied For:

Desired Salary:

Date Available:

Full Time

Part Time

Days

Evenings

Nights

Other

EDUCATION

H.S. / College / Vocational:

Major:

Degree Received:

Year Received:

From:

To:

H.S. / College / Vocational:

Major:

Degree Received:

Year Received:

From:

To:

H.S. / College / Vocational:

Major:

Degree Received:

Year Received:

From:

To:

H.S. / College / Vocational:

Major:

Degree Received:

Year Received:

From:

To:

CERTIFICATIONS AND LICENSURES

Type:

Certification/License#:

Expiration Date:

State:

Type:

Certification/License#:

Expiration Date:

State:

Type:

Certification/License#:

Expiration Date:

State:

Are you able to perform the essential job functions of the position for which you are applying with or without reasonable accommodation

Yes

Have you been convicted of any felonies other than minor traffic violations during the past seven years (A criminal record or a conviction will not automatically bar employment, but will be considered only as it reasonably relates to your fitness to perform in the position for which you are applying.)

Yes

Are you able at time of employment, to submit verification of your legal right to work in the U.S.?

Yes

PROFESSIONAL REFERENCE

Name:

Relationship:

Company:

Address / State:

Phone:

Email:

May we contact?

Yes

Name:

Relationship:

Company:

Address / State:

Phone:

Email:

May we contact?

Yes

Name:

Relationship:

Company:

Address / State:

Phone:

Email:

May we contact?

Yes

GENERAL INFORMATION

WORK HISTORY

Start with your present job and include any job related military service assignments. If you need additional space, please continue on a separate piece of paper. Please be sure to list all former employers within the last three years.

Company:

Phone:

Address / City / State / Zip:

Supervisor Name / Phone:

Position Held:

Salary:

Employment Dates From / To:

Reason For Leaving:

Company:

Phone:

Address / City / State / Zip:

Supervisor Name / Phone:

Position Held:

Salary:

Employment Dates From / To:

Reason For Leaving:

Company:

Phone:

Address / City / State / Zip:

Supervisor Name / Phone:

Position Held:

Salary:

Employment Dates From / To:

Reason For Leaving:

May we contact your present Employer?

Yes

Previous Employer?

Yes

SUBMISSION CONFIRMATION

I understand that if employed by Advanced Staffing Associates, and affiliates, I will be an employee at will, which means that I can voluntarily end my employment or be terminated at any time with or without notice for any reason or no reason at all. No statement whether written or oral, by any Company representative may vary the foregoing, I give the Company permission to verify all information provided on the application or in the interview(s), as well as contacting any and all or any of my previous employers and references and authorize them to provide all information requested of them by the Company.

After a conditional offer of employment has been made, if requested by the Company, I agree to take a job-related medical examination including a pre-employment drug test at no personal expense and authorize the examining physician to disclose the findings to the Company. I understand that any offer of employment is conditioned upon receipt of satisfactory references and satisfactory completion of such job-related medical examination and my receipt of negative drug test results.

I have provided truthful and complete responses to all inquiries in the application and understand that the discovery of any false or misleading information or the failure to provide information constitutes a ground for immediate dismissal. If employed, I will abide by the Company’s rules and regulations, which I understand are subject to change by the company.

I have read the foregoing and understand the above. By providing the above authorization I release Advanced Staffing Associates and affiliates from all liability for requesting and acting upon the information, reports and records obtained.

Electronic Signature:

Date:

Call us today at 959-206-8041 and allow us to find the professionals for you!

Serving all of Connecticut, Advanced Staffing Associates is committed to ensuring that you have a positive experience.