Application Form

First Name

Last Name

Phone

Social Security Number

Date of Birth

Sex

Address

City

Zip Code

Emergency Contact Name

Emergency Contact Phone

Higest Level of Qualification

Do you have a current CPR?

Date of Expiry

Have you taken a Food Safety Course?

Do you hold a current CMT?

Date of Expiry

Do you have a current First Aid Certification?

Date of Expiry

Work Availability

Have you ever been investigated for abuse, neglect or violence before?

List any Working Limitation you May Have

Transportation Type

Do you have a valid driver's license?

Company Name

Telephone

Address:

Supervisor's Name

Telephone

Address:

Authorization

Additionally, I authorize former employers, references and any of the individual organization to provide information to Absolute Staffing LLC and I hereby release any of the above and Absolute Staffing LLC from any liability of any kind or nature. I also understand that it is my responsibility to keep such information correct and accurate by updating it as it is often necessary.

Authorization

I agree to physical examination if requested and understand that failure to meet any medical and/ or health requirement for this position may prevent my employment with the agency. I also understand that employment, for certain position, may be conditional upon the successful completion of substance abuse screening test, if part of the agency pre-employment policy. I understand that, if hired, I may be required to provide proof that I am citizen of the United States or proof that i am currently authorized to work in the United States.

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Date

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