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Employment Application

An Equal Opportunity Employer

Thank you for your interest in applying for a job with DeLong Staffing Specialists and its affiliated companies, hereafter, the "Company". In order to get a complete understanding of your qualifications, interest and skill level, please answer this application honestly, thoughtfully and completely. DeLong Staffing Specialists is dedicated to a policy of non-discrimination in employment. No question is asked for the purpose of excluding any applicant due to race, creed, color, national origin, religion, age, sex, disability, marital status, veteran status, citizenship or any other characteristic protected by law. Applicants with disabilities may request a reasonable accommodation in order to perform the essential functions of a given job under the Americans with Disabilities Act and certain state or local laws. A reasonable accommodation is a change in the work process which provides an equal employment opportunity without imposing an undue hardship on the Company.

Please inform the Company's personnel representatives if you wish to request a reasonable accommodation, if you need assistance completing any forms or to otherwise participate in the application process.

(*) - Required field

Date

Position I'm interested in

Personal Information

Last Name

First Name

M.I.

Social Security Number

For example, 555 11 0000

Present Street Address

City

State

Zip

Home Phone

Cell Phone

Emergency Contact

Relationship

Phone

Shift Available to Work? 1st 2nd 3rd

Do You Have a Car? Yes No

Valid License? Yes No

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Disclosure and Consent

In connection with my application for employment (including contract for services) with you, I understand that investigative background inquiries are to be made concerning myself including consumer reports, investigative consumer reports, criminal, driving and other report. These reports may include information as to my character, credit worthiness, general reputation, personal characteristics, and mode of living, work habits, performance, and experience which involves personal interviews with sources such as neighbors, friends, or associates. I authorize, without reservation, any party or agency contracted by this employer or its agent to furnish the above-mentioned information. *** Date of Birth is being requested to obtain accurate retrieval of records.

I certify that these facts are true and complete to the best of my knowledge. I understand, if employed, false statements shall be grounds for dismissal. I authorize investigation of all statements herein. I also authorize the above references to give any and all information concerning my previous employment. I release all parties from liability of any damage that may result from furnishing same. I understand and agree, if hired, my employment if for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without notice. I further understand and agree that if placed by DeLong Staffing Specialists at any company, I cannot work for that company(s) for a minimum of 180 days after termination of employment through DeLong Staffing Specialists, regardless of the reason.

Signature (Type Name to Sign)

Date of Birth

Comments or Questions