Employment Application

Are you at least 18 years of age and do you have the legal right to work in the United States?

Yes

Name

First Last

Nickname / Preferred Name

SS Number:(Required)

Date Of Birth(Required)

Do you have a valid Driver's License?(Required)

State Issued Driver's License or Identification Number(Required)

State of Issuance

Expiration Date(Required)

Address

Street Address/Apartment City State ZIP / Postal Code

Home Phone(Required)

Other Phone(Required)

Email Address(Required)

Resume – If you have a plain-text resume, paste it into the box below.

Resume Upload

Max. file size: 2 MB.

Availability

Select the branch you are applying to:(Required)

Are you willing to work temporary?

Yes

Are you looking for a full-time career position?

Yes

Are you looking for contract positions?

Yes

When are you available to start?

What weekday hours are you available?

What weekend hours are you available?

How many hours are you willing to work in a week?

Are you willing to work overtime?

Yes

What is the minimum pay you desire?

How many miles are you willing to travel to a position?

How much notice will you need if a position is offered to you?

Education

Enter most recent – Do not enter start and end date if the most recent is high school

Name of School

Type of school

Street Address

City

State / ZIP Code

ZIP Code

Start Date (Month / Year)

End Date (Month / Year)

Degree

Major Study Area

Other Studies

Recent Employment

List most recent first

Company Name(Required)

Address

Street Address City State / Province / Region ZIP / Postal Code

Supervisor Name

Job Title

Job Duties

Start Date (Month / Year)

End Date (Month / Year)

Start Wage

Hourly rate or annual salary

End Wage

Hourly rate or annual salary

May we contact this employer for a reference check?

Yes

Company Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Supervisor Name

First Last

Job Title

Initials:

Job Duties

Start Date (Month / Year)

End Date (Month / Year)

Start Wage

Hourly rate or annual salary

End Wage

Hourly rate or annual salary

May we contact this employer for a reference check?

Yes

Company Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Supervisor Name

First Last

Job Title

Job Duties

Start Date (Month / Year)

End Date (Month / Year)

Start Wage

End Wage

May we contact this employer for a reference check?

Yes

Criminal Background & Drug Screen

Authorization for Background Check

In connection with my application for employment (including contract or volunteer services), I understand that a consumer report, and/or investigative consumer report, which may include information about my character, general reputation, personal characteristics, and mode of living, may be obtained. This may include motor vehicle records (MVR), criminal background checks, and other relevant information.

I hereby authorize the procurement of such report(s) and understand that this authorization shall remain on file and shall serve as ongoing authorization for the procurement of consumer reports at any time during my employment or contract period.

I acknowledge that I have received a separate document entitled “Summary of Your Rights Under the Fair Credit Reporting Act.”

Full Name (Printed): Electronic Signature (Type Your Full Name):

By typing your name, you agree this is your electronic signature under the E-SIGN Act.

Date:

Click here to view the Summary of Your Rights Under the Fair Credit Reporting Act (PDF)

Have you been convicted of a crime in the last 7 years, other than a minor traffic violation? If yes, please explain:

Yes

Please explain

Are you willing to take a drug screening test?

Yes

Special Skills and Qualifications

INDUSTRIAL SERVICES

MACHINE OPERATION

OFFICE / PROFESSIONAL

ACCOUNTING

CONSTRUCTION

MINING

VEHICLE & EQUIPMENT OPERATION

Forklift Operator

Stand Up Reach Forklift

Overhead Crane Operator

Cherry Picker

Clamp

Commercial

CDL

INDUSTRIES

WELDING

LANGUAGES

MEDICAL

CMA

Billing

Medical Records

Lab Tech

Insurance

Applicant Statement(Required)

I agree to the statement below

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

I authorize the use of any information in this application to verify my statements, and I authorize the past employers, all references, and other persons to answer all questions asked concerning my ability, character, reputation, and previous employment record. I release all such persons from any liability or damages on account of having furnished such information.

I understand that nothing contained in this employment application or in the granting of any interview is intended any benefit. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon Holden Temporaries, Inc. unless made in writing. If an employment relationship is established, I understand that I have the right to terminate my employment at any time and Holden Temporaries, Inc. retains the same right.

I understand that prior to being offered employment with Holden Temporaries, Inc. I may be requested to take an examination. In the event I have a disability which will affect my ability to take the test, I will so inform Holden Temporaries, Inc. prior to the administration of the test so that a reasonable accommodation can be made. Requested accommodations may include accessible testing sites, modified testing conditions, and accessible testing formats. Holden Temporaries, Inc. reserves the right to require medical documentation concerning the need for accommodation.

I further understand that if an offer of employment is tentatively made to me, it might be conditioned upon my successful completion of a medical examination. I understand that if employed, policies and rules which are issued are not conditions of employment and that the employer may revise policies or procedure, in whole or in part, at any time. The application for employment shall be considered active for a period of time not to exceed 12 months.

If your phone number or address changes during this time, please let us know so that we can still get in touch with you when an opening becomes available. 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, and business I am sent to.

Electronic Signature (Type Your Full Name):

By typing your name, you agree this is your electronic signature under the E-SIGN Act.

Date:

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Employment Application

Authorization for Background Check

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