1. Application 2. References 3. Pre-Tests 4. Skills 5. Documents
PERSONAL INFORMATION   (All fields with * are required.)
First Name:*
Last Name:*
Social Security Number:* - -
Present Address: *
City:*
State:*
Zip Code:*  
Permanent Address: (same as present:)  
City:
State:
Zip Code:  
Phone Number: * - -
Email Address:*
What website did you see this job posted on?
EMPLOYMENT DESIRED
Position:
State License #1:*   
State License #2:    
State License #3:    
State License #4:    
Date you can start:* /  
Salary Desired:  /Hr
Are you employed?* Yes No
May we contact your employer? * Yes No
Are you interested in a local or travel position? * Local Travel Both
How many hours per week will you be available to work with Dependable Staffing?*
8-16 hours
16-32 hours
32-40 hours
40+ hours
Please indicate your level of experience in the position for which you are applying. *
1-6 months
6 months-1 year
1-3 years
More than 3 years
Please indicate which shifts you will consider. (Check all that apply) *
Days
Evenings
Nights
Weekends
Have you applied with Dependable Staffing before? * Yes No
Where?*
When?*
EDUCATION
High School:
Name and Location:*
Number of Years Attended:*
Did You Graduate?* Yes No
Subjects Studied:
College:
Name and Location:
Number of Years Attended:
Did You Graduate? Yes No
Subjects Studied:
Trade, Business or Correspondence School:
Name and Location:
Number of Years Attended:
Did You Graduate? Yes No
Subjects Studied:
GENERAL
Subject of special study/research work/special training/skills/additional licenses held (current only):
Have you ever had a license or certification revoked or suspended in any state? * Yes No
If you answered yes, please explain: *
Were you reinstated?* Yes No
FORMER EMPLOYERS
(List below your last four employers, starting with the most recent)
Date From:*
Date To:*
Name of Employer: *
Address of Employer: *
Salary:* /Hr
Position:*
Reason for Leaving: *
Date From:* /
Date To:*
Name of Employer: *
Address of Employer: *
Salary:* /Hr
Position:*
Reason for Leaving: *
Date From:*
Date To:*
Name of Employer:*
Address of Employer:*
Salary:* /Hr
Position:*
Reason for Leaving:*
Date From:
Date To:
Name of Employer:
Address of Employer:
Salary: /Hr
Position:
Reason for Leaving:
REFERENCES
List below the names of three persons not related to you, who you've known at least one year.
Name:*
Address:*
Business:*
Number of Years Known: *
Name:*
Address:*
Business:*
Number of Years Known: *
Name:
Address:
Business:
Number of Years Known:
APPLICATION AUTHORIZATION AND RELEASE
* I understand and acknowledge that this application and the information provided or contained herein do not constitute an offer of employment. I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed; falsified statements on the application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information. Further, I release all parties (Dependable Staffing and its agents) and persons connected with any requests for information from all claims, liabilities, and damages for whatever reason, arising out of furnishing any information that may be sought in arriving at an employment decision. Due to the large number of applications that Dependable Staffing receives, I understand that Dependable Staffing cannot make any guarantees that my application will be considered for any or all open positions that Dependable Staffing may have currently or receive in the future, or that my application will be considered for any specific length of time. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in dismissal. I also understand that I am required to abide by all current and subsequently issued policies and procedures of Dependable Staffing and that employment is for no definite period and may be terminated, at any time, with or without notice, by either party. Pursuant to Arizona state law, Dependable Staffing currently participates in the E-Verify program ( Everify Poster English) or ( Everify Poster Spanish) to verify the eligibility of all newly hired employees to work in the United States.
1)   Signature:   Date:  
COMPANY POLICIES
SUBSTANCE ABUSE POLICIES ACKNOWLEDGEMENT AND ACCEPTANCE
* I hereby acknowledge that I have received, read, understand and agree to comply with the Dependable Staffing Services' Substance Abuse Policy (pdf).  Furthermore, I understand that this document does not constitute an obligation or contract of employment.
2)   Signature:   Date:  
PERSONNEL POLICIES ACKNOWLEDGEMENT AND ACCEPTANCE
Due to the dynamic nature of our business, the growth of Dependable Staffing Services, and the suggestions you and your fellow employees may make, Dependable Staffing reserves the right to interpret, amend, modify, or cancel and withdraw any or all sections or provisions of this manual at any time.

The policies and guidelines summarized here have been adopted voluntarily by Dependable Staffing for its employees and are not intended to give rise to contractual rights or obligations, nor to be construed as a guarantee of employment for any specific period of time or any specific type of work.

The policies and procedures described herein are summarized.   If you need additional information about any items covered here or about your job, you are encouraged to contact your Staffing Coordinator or a Dependable Staffing Manager.
* I hereby certify that as of the date below, I have read, understand, and agree to comply with Dependable Staffing Services' Personnel Policies (pdf).   I also understand that failure to do so may result in disciplinary action up to and including termination.
3)   Signature:   Date:  
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