Employment Application

Check one*
 Mr Ms

First Name*

Last Name*

Verify First Name*

Verify Last Name*

Please verify this is your legal name as it appears on your identification. *

Address*

City*

State*

Zip*

Email*

Preferred Name*

Phone*

Alternate Phone*

ADDITIONAL INFORMATION

Date Available

Desired Salary Range*

Have you ever applied to any of our offices before?*
 Yes No

Have any of your friends and family worked for the Employer, now or in the past?*
 Yes No

Are you 18 or older?*
 Yes No

When you interview with our service, will you be able to provide the following valid documentation?*

Identity (Picture ID)*
 Yes No

Eligibility to Work in the US*
 Yes No

Information provided is subject to verification with the Social Security Administration and/or the US Citizenship and Immigration Services.

List all other names by which you've been known.*

Please explain any additional information relative to a change of name, use of an assumed name, or nickname necessary to enable a check on your work and educational record?*

Have you been a temporary with another service before? *
Yes No If YES, we will ask you to complete a Temporary Experience Supplement during your interview.
 Yes  No

Some positions may require the ability to speak more than one language. If you would like to be considered for such positions, list all languages spoken other than English.
Hold the Ctrl key (on a PC) or the Command key (on a Mac) and click to select multiple languages.

Where Did You Hear About Us*

Assignment Information

Asmt No.

WORK PREFERENCES

Type of work desired*

Shifts available*
 1st 2nd 3rd Weekends

Hours Available*
 Full-time Part-time

Minimum Pay Rate $*

Miles willing to travel?*

LEGAL QUESTIONS

Have you been discharged or asked to resign from any job? *
If YES, please explain the circumstances.
 Yes No

Have you ever been reprimanded, suspended with or without pay, or terminated for fighting on the job, whether or not it was your fault? * If YES, please explain.
 Yes No

Will any of your work references disclose/reveal anything negative?*
If YES, please explain.
 Yes No

If a driver license is required for the position for which you are applying, do you have a valid license? *
License No. Exp. Date State of Issue

 Yes No

Have you ever plead guilty, "no contest", or been convicted of a felony or misdemeanor crime since the age of 18, including such moving violations as driving under the influence of a drug or alcohol, which were not later expunged?
If YES, please give dates and details.

 Yes No

Are you currently out on bail, or on your own recognizance pending trial, for an arrest? (NOTE: Answering "YES" to the above questions does not constitute an automatic bar to employment. Each case will be determined on its own merits.) *
If YES, please give dates and details of such arrest.

 Yes No

Are you currently using illegal drugs? *
If YES, which illegal drugs have you recently used?

 Yes No

If YES, when did you recently use each of these drugs?

EDUCATION Please enter your highest level of education.

School Name *

List any special trade or
vocational schools attended: *

Location (City, State)*

List any professional or vocational certificates, licenses, or registrations that you currently hold or have held in the past:*

Major/Subject*

G.P.A.

Describe any specialized training, apprenticeship, skills, extracurricular activities, honors, scholarships, appointments, awards, or special recognition that you have received:

Diploma/Degree*

EMPLOYMENT HISTORY

Please provide your employment history for the past 10 years as follows:

  • Begin by entering the date range of your most recent job or period of unemployment.
  • Once you have entered the dates you will be asked to indicate whether you were employed or unemployed between those dates.
  • Once you have indicated whether or not you were employed during the stated period of time, the required data fields will be indicated by a red asterisk.
  • Input the requested information into the required fields with the red asterisk.
  • Click the (+) sign to add the next entry. You may add up to ten periods (date ranges for work or periods of unemployment) to encompass the past ten years.
  • Be sure to account for all time periods including school, military service and self employment. For periods of unemployment please use the Duties/Details field to explain or comment.

Employment History #1

Were you employed during this period? *
If YES, please complete the company information. Yes No
If NO please explain this gap below.

Starting Date*

Ending Date*

Duties/Details

Company Name

Supervisor

City

State

Title

Phone

Reason for Leaving

Starting Wage Per Hr

May we contact this employer?
 Yes No

If NO, please explain.

Employment History #2

Were you employed during this period? *
If YES, please complete the company information. Yes No
If NO please explain this gap below.

Starting Date*

Ending Date*

Duties/Details

Company Name

Supervisor

City

State

Title

Phone

Reason for Leaving

Starting Wage Per Hr

May we contact this employer?
 Yes No

If NO, please explain.

REFERENCES List three additional business/professional references who have known you for at least one year. DO NOT LIST PERSONAL REFERENCES.

Reference 1

Name

Business

Phone

Address

Years

Reference 2

Name

Business

Phone

Address

Years

Reference 3

Name

Business

Phone

Address

Years

EMERGENCY CONTACTS

Name

Phone

Name

Phone

PAYROLL

Please check how you would like your payroll handled upon hire. *

Dectly deposited to my bank account. (Direct Deposit form must be submitted to the Employer.)

Deposited onto a pay card. (Enrollment form must be submitted to the Employer.)

SKILLS

Please click on the skills that best describe your experience. Opportunities to expand your abilities may be available at the time you are considered for a position. *

CLERICAL INDUSTRIAL
• ACCOUNTING
• BANKING/MORTGAGE
• CERTIFICATIONS • CERTIFICATIONS
• CLERICAL • COMPUTER APPLICATIONS
• COMPUTER APPLICATIONS • CONSTRUCTION
• CUSTOMER SERVICE • DRIVERS
• DATA ENTRY • ELECTRICAL/MECHANICAL ASSEMBLY
• HUMAN RESOURCES • FOOD SERVICE
• INSURANCE • GENERAL LABOR
• MARKETING/SALES • MACHINE OPERATOR
• MEDICAL/DENTAL • MAINTENANCE
• PURCHASING • PRODUCTION
• RECEPTIONIST • WAREHOUSE
• SECRETARIAL

Have you held either of these positions?

Managerial Supervisor

Legal Acknowledgements
APPLICANT'S AGREEMENT
AT-WILL

I understand that Global Personnel Solutions, Inc. does not hire everyone who fills out an application for employment and that all applicants must meet certain general hiring criteria set forth by Global Personnel Solutions, Inc., such as having the legal right to work in the U.S., appropriate skills, job history, and favorable references. Applicants must also have personal qualities such as being honest, trustworthy, non-violent, and reliable. I understand that Global Personnel Solutions, Inc. does not discuss hiring or placement criteria or hiring decisions with applicants or employees, and that Global Personnel Solutions, Inc. does not discuss termination decisions with employees. I understand that my employment at Global Personnel Solutions, Inc. is on an at-will basis and that I may be terminated at any time, with or without cause, and with or without notice, either at my option or at the option of Global Personnel Solutions, Inc.. In consideration of my employment, I agree to conform to the rules and standards of Global Personnel Solutions, Inc., as amended by Global Personnel Solutions, Inc. from time to time at their discretion. I further agree that my employment and compensation is for no definite period. Terms and conditions of employment including promotions, change in job duties, locations, and compensation can be changed at the sole discretion of Global Personnel Solutions, Inc., at any time, with or without cause, advance notice, or stated reason. Global Personnel Solutions, Inc. may warn, reassign, suspend, demote, or terminate any employee in their sole discretion, at any time, with or without cause, advance notice, or stated reason. I understand that no employee or representative of Global Personnel Solutions, Inc., other than the Chairman & CEO, has the authority to enter into any agreement for employment for any specified period of time, or to make any agreement or condition contrary to the foregoing. Further, the Chairman & CEO of Global Personnel Solutions, Inc. may not alter the at-will nature of this employment relationship unless he signs a written document in which he specifically and clearly indicates the intent to do so.

Please initial authorization and consent for AT-WILL section*

VERIFICATION & RELEASE

I hereby certify that the information supplied on this application for employment is true and correct to the best of my knowledge, and agree to have any of the statements checked by Global Personnel Solutions, Inc., unless I have indicated to the contrary. I authorize Global Personnel Solutions, Inc. to contact any and all of the references listed (including employers and schools), and I authorize those references to provide Global Personnel Solutions, Inc. any and all information concerning my previous education and employment and any other pertinent information that any of them may have or know about me. Further, I release all parties, companies, and persons providing such information to Global Personnel Solutions, Inc. from any liability for any damages that may result from furnishing such information to Global Personnel Solutions, Inc. as well as from the use or disclosure of such information by Global Personnel Solutions, Inc. or any of their agents, employees, or representatives. I understand that any misrepresentation, falsification, or material omission of information on this application or during the interview process (regardless of when discovered) may result in my failure to receive an offer or, if I am hired, my immediate termination from employment at any time.

I understand that on some jobs I may be offered full-time employment. This may be approved if Global Personnel Solutions, Inc. is notified prior to my accepting the full-time assignment and after I have completed the number of hours mutually agreed upon by Global Personnel Solutions, Inc. and the client.

I understand that at the end of an assignment it is my responsibility to contact Global Personnel Solutions, Inc. immediately to report my availability. I will become an employee upon commencing a paid assignment with a client of Global Personnel Solutions, Inc.. When my assignment with any particular client ends, I will remain an employee of Global Personnel Solutions, Inc., however unpaid and not on active duty, and Global Personnel Solutions, Inc. will continue its efforts to find me a new assignment. The end of any particular assignment with a client does not end my employment relationship with Global Personnel Solutions, Inc.. My employment relationship with Global Personnel Solutions, Inc. will end only on the occurrence of one of the following three events: I tell Global Personnel Solutions, Inc. that I am not interested in additional assignments from Global Personnel Solutions, Inc.; Global Personnel Solutions, Inc. tells me that I am not eligible for additional assignments from Global Personnel Solutions, Inc.; or 14 days pass after the end of my last assignment with a client of Global Personnel Solutions, Inc., and Global Personnel Solutions, Inc. has not offered me a new assignment which I have accepted.

I acknowledge that I am not eligible to receive the benefits offered by Global Personnel Solutions, Inc.'s clients to their employees.

I also understand that any offer of employment from Global Personnel Solutions, Inc. is conditional on Global Personnel Solutions, Inc. receiving satisfactory responses to reference requests, passing a drug screen, and providing satisfactory proof of my identity and legal authority to work in the United State.

This application will be considered active for a maximum of thirty (30) days. If you wish to be considered for employment after that time, you must reapply.

Please initial authorization and consent for VERIFICATION & RELEASE section*

DISCRIMINATION AND REPORTING POLICIES

Global Personnel Solutions, Inc. does not discriminate against their applicants or employees in any manner, and cannot and will not tolerate any form of harassment, including sexual harassment, or discrimination of any type, whether based on sex, race, age, national origin, ancestry, religion, sexual orientation, marital status, or physical or mental disability, toward our employees. Global Personnel Solutions, Inc. is an Affirmative Action and Equal Opportunity Employer. If you believe that you (or another co-worker) have been discriminated against or harassed by a co-worker, supervisor, agent of Global Personnel Solutions, Inc., or a customer, you should immediately report the facts of the incident and the names of the individuals involved to the Corporate Human Resources Director, who will promptly investigate all claims and take appropriate action. Call 1-800-609-7122 or 706.722.4222 ext. 229

Please initial authorization and consent for AUTHORIZATION AND CONSENT FOR DRUG SCREENING section*

MUTUAL AGREEMENT REGARDING ARBITRATION AND CLASS CLAIMS

In the event there is any dispute between Employer and I relating to or arising out of or relating to my employment or the termination of my employment, which Employer and I are unable to resolve informally through direct discussion, regardless of the kind or type of dispute, Employer and I agree to submit all such claims or disputes to be resolved by final and binding arbitration in accordance with the National Rules for the Resolution of Employment Disputes of the American Arbitration Association within the state of employment. Said disputes may include but are not limited to claims for or under: breach of contract, fraud, misrepresentation, defamation, personal injury, wages, salary, wrongful termination, vacation pay, sick pay, overtime pay, the Federal Labor Standards Act and comparable state laws, the Civil Rights Act of 1964, as amended, 42 U.S.C. section 1981, the Americans with Disabilities Act, laws that prohibit discrimination based on religion, sex, age, color, nationality, physical impairment, disability, medical condition, marital status, or other basis, the Family and Medical Leave Act, the Employee Retirement Income Security Act (ERISA), and state laws regarding unfair competition or unfair business practices.

Any such claims must be submitted on an individual basis only and I hereby waive the right to bring or join any type of collective or class claim in arbitration, in any court, or in any other forum. This class/collective action waiver does not apply to claims brought under the National Labor Relations Act (NLRA). I may challenge the enforceability of this class/collective action waiver under the NLRA or in any other forum, and Employer agrees that it will not retaliate against me or any employee who challenges the enforceability of this waiver; however, Employer reserves all rights to seek to fully enforce the waiver and compel arbitration on an individual basis. Consolidation of claims absent consent of all the parties to the dispute is also prohibited. Any claims must be filed within the statute of limitations applicable to filing such claim in court or in an administrative proceeding. All remedies available through a court or administrative action are available through arbitration. Either party to this agreement may be represented by counsel at any arbitration proceeding and either party retains the right to seek injunctive relief in aid of arbitration.

Please initial authorization and consent for MUTUAL AGREEMENT TO ARBITRATE section*

AUTHORIZATION FOR RELEASE OF EMPLOYMENT/MEDICAL RECORDS

For the duration of my employment, I give permission to Global Personnel Solutions, Inc. to furnish and release to its Workers' Compensation carrier and/or administrator, or any representative thereof, the following information:

1. All medical records pertaining to examinations, treatments, or consultations, including but not limited to, billing records; x-rays and reports; history records; diagnosis and prognosis records; nurses' and doctors' notes and all reports and any psychiatric or mental health records; and all reports relating to diagnosis, care and treatment for drug and alcohol abuse.

2. All employment records pertaining to employment with Global Personnel Solutions, Inc. and any previous employer, including but not limited, to personnel records, payroll records, medical records, and time records.

I understand that the information obtained will be used by Global Personnel Solutions, Inc.'s Workers' Compensation carriers and/or administrators for the evaluation and processing of any claims for Workers' Compensation benefits as a result of any work-related injuries. I do not give permission for any other use or re-disclosure of this information.

This Authorization is valid until my claim has been accepted or denied, but in no event beyond one year from the date of my injury. A photocopy of this Authorization is as effective as the original. I understand that I am entitled to a copy of this Authorization.

Please initial authorization and consent for AUTHORIZATION FOR RELEASE OF EMPLOYMENT/MEDICAL RECORDS section*

FCRA Disclosure

As part of the application process for employment at the Employer, I understand that the Employer may request my consent to seek and obtain consumer reports / investigative reports about me as defined in the Fair Credit Reporting Act (FCRA). These investigative reports may include, but is not limited to names and dates of previous/current employment, work experience, work habits, characters, work performance, general reputation, workers compensation claims, criminal history records (from local, state, federal, international and other law enforcement agencies' records), sexual offender's lists, wants and warrants records, motor vehicle records, military records, educational verification, license verification, credit history, credit worthiness, civil case, OIG/GSA, OFAC/patriots act, any sanction lists, FBI finger printing and drug testing. I understand that these records may be used for the eligibility and qualification of my employment.

Please initial to indicate that you have read the FCRA Disclosure*

I hereby certify that the information supplied on this application for employment is true and correct to the best of my knowledge, and agree to have any of the statements checked by Global Personnel Solutions, Inc., unless I have indicated to the contrary.

By signing I acknowledge that I have read and understood all of the above statements.

Signature*
Please enter your name in the
same format that you sign your name

Signature Date*