Application for Employment

First: Middle Init: Last:

Date:

Address:

City:

State:

Zip:

Phone:

Cell:

E-mail:

Emergency Contact: Phone Number:

Please Indicate your Specialty:	Other:

License Number:

State Issued:

School, College/University or Vocational School Attended

Name:

Dates Attended:

From

Address:

City:

State:

Zip:

Experience

Name of present or last employer
Address
City	State: Zip:
Starting Date	Ending Date
Hr/Mo Starting Salary	Hr/Mo Final Salary
Job Title	Position Duty
Description of work
Name and Title of immediate supervisor
Was termination?: Voluntary Involuntary
Exact reason for leaving
May we contact this employer? Yes No

2. Name of present or last employer
Address
City	State: Zip:
Starting Date	Ending Date
Hr/Mo Starting Salary	Hr/Mo Final Salary
Job Title	Position Duty
Description of work
Name and Title of immediate supervisor
Was termination?: Voluntary Involuntary
Exact reason for leaving
May we contact this employer? Yes No

3. Name of present or last employer
Address
City	State: Zip:
Starting Date	Ending Date
Hr/Mo Starting Salary	Hr/Mo Final Salary
Job Title	Position Duty
Description of work
Name and Title of immediate supervisor
Was termination?: Voluntary Involuntary
Exact reason for leaving
May we contact this employer? Yes No

4. Name of present or last employer
Address
City	State: Zip:
Starting Date	Ending Date
Hr/Mo Starting Salary	Hr/Mo Final Salary
Job Title	Position Duty
Description of work
Name and Title of immediate supervisor
Was termination?: Voluntary Involuntary
Exact reason for leaving
May we contact this employer? Yes No

What is your availability?

Have you ever worked for Pro-Tem Personnel before?

Yes No

If you answered yes to the previous question, when?

If hired, can you present evidence of your U.S. citizenship or proof of your legal right to work in this country?

Yes No

Do you write or speak a foreign language? Yes No

If yes, please indicate the language and your level of proficiency:

Have you ever been convicted of a criminal offense (felony or serious misdemeanor

Yes No

If yes, please explain:

Have you ever been denied a bond?

Yes No

PRO-TEM Personnel requires all applicants to submit proof of annual physical and TB once a year. If your TB test was positive, then the results of your chest x-ray are necessary prior to employment. Chest x-rays are valid for 2 years.

A physical information sheet, drug consent form and background check are required from all applicants prior to your interview with our staffing consultants.

By submitting your application via our Website you are certifying you have not knowingly withheld any information that might adversely affect your chances for employment and that your answers are true and correct to the best of your knowledge. Any misstatement of material fact on this or any other document used to secure employment shall be grounds for rejection of the application or for immediate discharge if employed, regardless of the time elapsed before discovery.

Your application submission further authorizes PRO-TEM Personnel to thoroughly investigate your references, work record, education and other matters related to your suitability for employment. You also release PRO-TEM Personnel, former 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.

You understand that nothing contained in this application or conveyed during any interview which may be granted, or during your employment, if hired, is intended to create an employment contract between you and PRO-TEM Personnel. You also understand that if employed, your employment is for no definite or determinable period and may be terminated at any time, with or without notice, at the option of either yourself or PRO-TEM Personnel.

Should a search of public records (including records documenting an arrest, indictment, conviction, civil judicial action, tax lien or outstanding judgment) be conducted by internal personnel employed by PRO-TEM Personnel you will be entitled to copies of any such public records obtained by PRO-TEM Personnel.

I have read and agree to the above conditions

Yes