Do you have a High School Diploma or. GED? ... perform the work, such as schools, colleges, degrees, vocational or techn
EMPLOYMENT APPLICATION Please carefully read and answer all questions. You will not be considered for employment if you fail to completely answer all the questions on the application. You may attach a resume, but all questions must be answered. Position applying for:
.
PERSONAL DATA Name: Street Address:
City:
State:
Zip:
Mailing Address:
City:
State
Zip:
Home Phone:
Business Phone:
Message Phone:
Date you can start work:
Salary Desired:
Do you have a High School Diploma or GED? Yes No
POSITION INFORMATION Hours:
D D D
n
-n
Check all that apply
Full-time Part-time Supplemental
D D
D D
Days Evenings
If employed in this position, would you be in a supervisory
or subordinate
Have you ever been convicted of a felony? disposition of the case.
No
DYes
D
Status:
Graveyard Weekends relationship
D D
Regular Temporary
to any family members?
DYes
D
0
If yes, state nature of the crime(s), when and where convicted and
o applicant will be denied employment solely on the grounds of conviction of a criminal offense. The nature ofthe offense, (Note: date of the offense, the surrounding circumstances and the relevance of the offense to the positions(s) applied for may, however, be considered.)
QUALIFICATIONS
Please list any education or training you feel relates to the position applied for that would help you perform the work, such as schools, colleges, degrees, vocational or technical programs, and militarY training. Areas of Did You Degree School Name No. of Years Specialization Graduate? Received Address/Citv /State Cornoleted College Vocational/Technical Other
SPECIAL SKILLS
Please list any special skills or experience that you feel would help you in the position that you are
applying for.
REFERENCES relationship.
Please list three professional references not related to you with full name, address, phone number, and If you don't have three professional references, list personal unrelated references.
Name
Address/City/State
Phone
Relationship
We are an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities.
WORKIDSTORY Job Title:
List all present and past employment starting with your most recent emplover. End Date (mo/day/yr) Start Date (mo/day/yr) Name:
Phone Number:
Company Name:
Supervisor's
Address
City/State
Zip
Starting Salary:
Ending Salary:
Duties:
Reason for Leaving: May we contact your present employer?
DYes
D
No
Start Date (mo/day/yr)
End Date (mo/day/yr)
Company Name:
Supervisor's
Phone Number:
Address
City/State
Zip
Starting Salary:
Ending Salary:
Start Date (mo/day/yr)
End Date (mo/day/yr)
Company Name:
Supervisor's
Phone Number:
Address
City/State
Zip
Starting Salary:
Ending Salary:
Start Date (mo/day/yr)
End Date (mo/day/yr)
Company Name:
Supervisor's
Phone Number:
Address
City/State
Zip
Starting Salary:
Ending Salary:
Job Title:
Name:
Duties: Reason for Leaving:
Job Title:
Name:
Duties:
Reason for Leaving:
Job Title:
Name:
Duties:
Reason for Leaving:
___ I hereby authori=e the company to thoroughly investigate my references, work record, education and other mailers related to (Int'ls) my suitability for employment and, further, authorize the references I have listed to disclose to the company any and all letters, reports and other iriformation related to my work records, without giving me prior notice of such disclosure. In addition, 1 hereby release the company. myformer employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.
Applicant Signature
Date Revised 4/24/06
i••'i .-.
II 1.1 "_.~;jI
r
A- C H E C K America, Inc.
AUTHORIZATION For BACKGROUND INVESTIGATION File Number (online users only):
_
To Whom It May Concern: I, , hereby authorize A-Check America, Inc. and/or its agents to make an independent investigation of my background, which may include my character, general reputation, personal characteristics, and mode of living in connection with an application of employment with _ The Scope of the report may include information concerning my driving record, civil and criminal court records, credit, worker s compensation record, education, credentials, identity, past addresses, social security number, previous employment and personal references. I authorize and request any present or former employer, state/federal government office, state department of motor vehicles, credit bureaus, school, police department, court records, including those maintained by both public and private organizations, financial institution or other persons having personal knowledge about me to furnish A-Check America, Inc. with any and all information in their possession regarding me for the purpose of confirming the information contained on my Application and/or obtaining other information which may be material to my qualifications for employment. I am willing that a photocopy of this authorization be accepted with the same authority as the original, and I specifically waive any written notice from any present or former employer who may provide information based upon this authorization request. The following is my true and complete legal name and all information is true and correct to the best of my knowledge: Print Full Name:
_
Print Maiden Name or Other Names Used:
_
Present Address: City: Date of Birth (for J.D. purposes only): Social Security Number: Driver s License Number:
_ State:
Zip Code:
_
_ _ State of Issue:
A-Check America will need to contact you if additional information is needed to process your Background Investigation. Please provide a telephone/cell phone number where we may contact you. Phone: ( ) __ ... Cell:( __ ) _
NOTICE TO CALIFORNIA, MINNESOTA AND OKLAHOMA RESIDENTS: If you would like to receive a free copy of your background information obtained following box: DYes (please send me a copy of my Background Report)
Signature:
by A-Check
Date:
America,
please indicate
_
by checking
the
'Ii
.
I
Ii'
PRE- EMpLOYMENT QUESTIONNAIRE
DATE:
. ss#
NAME:
PHONE:
ADDRESS:
CELL:
HOW DID YOU HEAR ABOUT BARRETT BUSINESS SERVICES? D Walk-In D Yellow Pages D Friend/Relative D Web Site
D Other
HAVE YOU APPLIED AT ANOTHER BARRETT BUSINESS SERVICES BRANCH?
DYES
D NO
Which Branch?
If Yes, when did you apply?
WHAT TYPE OF JOB ARE YOU SEEKING?
(Checkall that apply)
o CLERICAL/PROFESSIONAL
DINDUSTRIALITECHNICAL
HOW MANY YEARS OF EXPERIENCE DO YOU HAVE IN THE FOLLOWING AREAS? CLERICAL _ADMIN _DATA
ASST.
_WORD
ENTRY CLERK
_SECRETARY
MANAGER
_CUSTOMER
_OFFICE
GENERAL OFFICE CLERK
PROCESSING
_RECEPTIONIST SERVICE
_OTHER
INDUSTRIAL _ASSEMBLY
_FORKLIFT
DRIVER
_CNC
_LOADING/UNLOADING
_MACHINE
OP.
_ORDER
PULLER
_PUNCH
PRESS
_PACKER
SHIP/RECEIVE
WHAT SHIFTS ARE YOU AVAILABLE TO WORK? (Checkall that apply)
MACHINIST
D2nd
0 1sl
D3rd
HOURLY RATE WILL YOU CONSIDER? DO YOU HAVE RELIABLE TRANSPORATION TO AND FROM WORK?
DYES
D NO
DO YOU HAVE VERIFIABLE WORK EXPERIENCE FOR THE LAST 6 MONTHS?
DYES
D NO
ARE YOU ABLE TO ESTABLISH PROOF OF ELIGIBILITY TO WORK IN THE U.S.?
DYES
D NO
HAVE YOU EVER BEEN CONVICTED OF A CRIME?
DYES
D NO
(Felony or serious Misdemeanor)
If yes, please complete the following:
NATUREOF CRIME
Please note that
a
WHEN AND WHERE CONVICTED
conviction may not necessarily disqualify an applicant for employment.
DISPOSITION
