Application for Employment
As part of the application process, Administaff may conduct background checks on applicants EQUAL OPPORTUNITY EMPLOYER. It is our policy to abide by all federal, state and local laws prohibiting employment discrimination based solely on a person's race, color, religious creed, sex, national origin, ancestry, citizenship status, pregnancy, physical disability, mental disability, age military status or status as a Vietnam-era or special disabled veteran, marital status, registered domestic partner status, gender (including sex stereotyping), medical condition (including, but not limited to, cancer related or HIV/AIDS related), sexual orientation, or any other protected status except where a reasonable, bona fide occupational qualification exists.
Name
Home Address
City
County
State
Zip
Last 4 Digits of Social Security Number
How long at current address?
Daytime Telephone
Home Telephone
E-mail Address
Position for which you are applying
What is your minimum salary requirement?
Check the following options you would consider
Full Time
Part Time
Temporary
If part time, specify hours or days available
Do you have any commitments to another employer that might affect your employment?
Yes
No
If Yes, explain:
Date available for work
EDUCATION AND TRAINING
School Name
City and State
Degree/Diploma
Major Course
Degree
Recieved?
High School/GED
Yes
NO
College
Yes
NO
Graduate School
Yes
NO
Trade School
Yes
NO
List any other education, training, special skills or certificates/licenses that you possess related to the job.
Professional License/Certification #
Professional License/Certification Type
Issuing Agency
State Issued
Expiration Date
Professional License/Certification #
Professional License/Certification Type
Issuing Agency
State Issued
Expiration Date
List any machines, equipment or software programs on which you are qualified and experienced in operating.
List any languages that you speak fluently
List any languages that you read/write fluently
If you are applying for a position which involves driving a motor vehicle in the course and scope of the employment duties, please indicate whether you have a valid driver's license in this state.
Yes
No
General Information
Can you, after employment, submit verification of your legal right to work in the United States?
Yes
No
Are you 16 years old or over? If under 18, state age.
Yes
No
Can you perform the essential functions of the job?
Yes
No
Employment History
List all work experience beginning with the present or most recent job.
Name of Employer
Type of Business
Address
City
State
Zip Code
Dates Employed From (month/year)
To (month/year)
Title
Name and Title of Supervisor
Telephone
May we contact?
Yes
NO
Employment Type
Full Time
Part Time
Reason for Leaving
Brief Description of Duties
Salary
Name of Employer
Type of Business
Address
City
State
Zip Code
Dates Employed From (month/year)
To (month/year)
Title
Name and Title of Supervisor
Telephone
May we contact?
Yes
NO
Employment Type
Full Time
Part Time
Reason for Leaving
Brief Description of Duties
Salary
Name of Employer
Type of Business
Address
City
State
Zip Code
Dates Employed From (month/year)
To (month/year)
Title
Name and Title of Supervisor
Telephone
May we contact?
Yes
NO
Employment Type
Full Time
Part Time
Reason for Leaving
Brief Description of Duties
Salary
Name of Employer
Type of Business
Address
City
State
Zip Code
Dates Employed From (month/year)
To (month/year)
Title
Name and Title of Supervisor
Telephone
May we contact?
Yes
NO
Employment Type
Full Time
Part Time
Reason for Leaving
Brief Description of Duties
Salary
Business References
(List three individuals, in addition to listed employment references, known to you for at least three years.)
Name
Occupation/Association
Telephone
Additional Information
Please include any other information you think would be helpful to us in considering you for employment, such as additional work experience, articles/books published, activities, honors received, etc. (You may omit all information that would indicate age, sex, sexual orientation, race, religion, color, national origin, or disability.)
Criminal Record Information
Instructions for answering the next two questions below:
A. All Applications
Do not include convictions that were sealed, eradicated, erased, annulled by a court, expunged, pardoned, or deferred and withdrawn.
B. District of Columbia, Illinois, and Rhode Island Applications.
Do not respond to the second question (regarding pending charges).
C. California Applicants.
Do not include: a misdemeanor conviction for possession or transportation of a small amount of marijuana (28.5 grams or less) if the conviction is more than two (2) years old; participation in any pretrial or post trial diversion program for drug or alcohol rehabilitation; or a misdemeanor conviction for which probation was successfully completed or otherwise discharged and the case was judicially dismissed.
D. Colorado Applicants
Exclude information involving any record of civil or military disobedience unless such matters resulted in a plea or guilty or a conviction by a court of competent jurisdiction.
E. Connecticut Applicants
You are not required to disclose the existence of any arrest, criminal charge, or conviction, the records of which have been erased. Criminal records subject to erasure are: records pertaining to a finding of delinquently or the fact that a child was a member of a family with service needs; an adjudication as a youthful offender; a criminal charge that has been dismissed or nulled (not prosecuted); a criminal charge for which the person was found not guilty; or a conviction for which the offender received an absolute pardon. Any person whose criminal records have been erased is deemed to have never been arrested within the meaning of the law as it applies to the particular proceedings that have been erased, and may so swear under oath.
F. Hawaii Applicants.
Do not answer the following two questions
G. Massachusetts Applicants.
Regarding convictions, exclude misdemeanor convictions more than five (5) years old and exclude a first offense for drunkenness, simple assault, speeding, minor traffic violation, affray, or disturbing the peace. Do not respond to the second question (regarding pending charges).
NOTE:
An applicant with a sealed record on file with the Massachusetts commissioner of probation may answer "no record" with respect to an inquiry herein relative to prior arrests, criminal court appearances or convictions. An applicant may answer "no record" to an inquiry herein relative to prior arrests, court appearances and adjudications in all cases of delinquency or as a child in need of services which did not result in a complaint transferred to the superior court for criminal prosecution.
H. Michigan Applicants.
regarding pending charges, limit your response to felony offenses.
I. Utah Applicants
Regarding convictions, limit your response to felony convictions, Do not respond to the second question (regarding pending charges).
1. Convictions/Please.
In the past ten (10) years, have you ever been convicted of, or pled guilty or no contest to, any criminal offense other than any applicable exceptions listed above?
Yes
NO
2. Pending Charges.
Have you been arrested for any matters for which you are now out on bail or on your own recognizance pending trial?
Yes
NO
CRIMINAL RECORDS:
If you answered Yes to either of the above two questions, please provide the date(s) and describe that criminal record so the individual circumstances can be considered.
Criminal convictions or arrests will not automatically disqualify an applicant from employment
Agreement(Please read the following statement carefully.)
I hereby affirm that the information provided on this application is true and complete to the best of my knowledge. I also agree that falsification or significant omission of information requested in this application or in the application process may disqualify me from further consideration for employment and may be considered justification for dismissal if discovered at a later date.
I authorize all persons listed above to give Administaff any and all information concerning my previous employment and eduction and any pertinent information they may have, personal or otherwise, and release all parties, such persons and Administaff, from liability for and damage that may result from furnishing same to Administaff.
I understand that Administaff and its client have agreed that Administaff will provide workers' compensation Insurance coverage for its employees. In the event of an injury in the workplace, I agree that my sole remedy lies in coverage under Administaffs workers' compensation insurance policy.
If employed by Administaff and its client company, I agree to abide by the policies and procedures of Administaff and its client company, which include Administaff's Anti-Harassment Policy. I further understand that my employment can be terminated, with or without cause or notice, at any time, at the discretion of Administaff, the client company or myself. I further understand that no manager or representative of Administaff or its client company other than the president of Administaff has any authority to enter into any agreement, oral or written, on behalf of Administaff for a term of emplayment of to make any assuance or promise of continued employment.
I understand that Administaff and/or its client company may obtain a consumer and/or investigative consumer report for employment purpose that may include information regarding prior employment, work experience and performance, reasons for employment termination, and information as to character, general reputation, personal characteristics, or mode of living. The report may also contain a records check of driving, criminal, credit, education, degrees, professional licenses and/or certification records depending on the position. By signing this application, I authorize the procurement of a consumer and/or investigative consumer report by Administaff as part of the pre-employment background investigation and if hired, at any time during my employment. California Applicants: I further understand that Administaff and/or its client company may obtain Public Records about me as part of an internal background investigation and that I may waive my right to recieve a copy of such Public Records by checking this box:
Attach Resume
UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A LIE DETECTOR OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISIDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $100.
I understand and agree that, subject to applicable law, I may be required to take a drug and alcohol screening test. I herby give my voluntary consent for a blood and/or urine sample to be collected from me and submitted for testing. I also consent to the release of the test results to Administaff and/or its client company. I understand that any positive drug or alcohol result may preclude my employment.
Sign and Date the form
Applicants Full Name
Last 4 Digits of SSN
Date Signed