Job Application Job Application Form "*" indicates required fields Step 1 of 9 11% Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Personal InformationName* First Last Address* Street Address / Apt # City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone Number*Email* Emergency Contact* Emergency Phone Number* Employment NeedsHow much advance notice?* Are you willing to work overtime?* Position* Desired Wage* Date You Can Start*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Position Type* PT FT Shifts you are available to work* Day Swing Graveyard Days you are available to work* Monday Tuesday Wednesday Thursday Friday Saturday Sunday Transportation* Private Public Other Bi-Lingual* Yes No Languages Spoken* How far can you travel for position?* How did you hear about Infinity Staffing?* Have you worked for Infinity Staffing?* Work HistoryPLEASE BEGIN WITH MOST RECENT EMPLOYERPosition Employer May We Contact? Yes No PhoneReason for Leaving Supervisor Address Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Start Date Month Day Year End Date Month Day Year NEXTPosition Employer May We Contact? Yes No PhoneReason for Leaving Supervisor Address Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Start Date Month Day Year End Date Month Day Year NEXTPosition Employer May We Contact? Yes No Phone Number Reason for Leaving Supervisor Address Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Start Date Month Day Year End Date Month Day Year EligibilityAre you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation?* Yes No If no, describe ReferencesName Title/Company Realationship PhoneNEXTName Title/Company Realationship PhoneNEXTName Title/Company Realationship Phone EducationHigh School Years Completed Did You Graduate? Yes No Degree or Diploma Address Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code NEXTCollege/University Years Completed Did You Graduate? Yes No Degree or Diploma Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands NEXTOther Year Completed Did You Graduate? Yes No Degree or Diploma Address Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code SkillsOffice Skills Filing Inventory Accounting Bookkeeper Assistant Payroll Accounts Payable Accounts Receivable Credit/Collections Bank Teller 10-Key Secretarial Skills Executive Adminstrative PC MAC Handheld Scanner Copier/Printer Office Equipment Multi-Line Phone Facsimile Typing Word Processor 10 Key Computer Software Windows MAC Microsoft Word Microsoft Excel Microsoft Powerpoint Microsoft Outlook Quickbooks Quicken Peachtree Construction Woodframe Brick Layer Carpentry Electrical Form Setting Masonry Heavy Operator Forklift Operator Warehouse Loading Driver CDL Class "A" Class "B" Class "C" Service Mechanics Auto Detailing Auto Body Repair Factory Inspection Plating/Anodizing Production/Fabrication Welding Retail Cashier Pricing/Tagging Phone Sales Counter Clerk Shipping/Receiving Medical Nurse CNA Medical Receptionist Medical Records Medical billing Housekeeping Hotel Hospital Laundry Room Maintenance Front Desk Housekeeping Production Packaging Quality Control Labeling Miscellaneous Dispatcher Server Bartender Other Add RemoveOther Add RemoveOther Add Remove RELEASE AND AUTHORIZATION FORMIn accordance with my right to privacy, I have been advised by INFINITY STAFFING that the information described below is required to assist the same in making and employment advancement determination concerning me and that execution of this form is voluntary. I hereby authorize any qualified agent bearing this document or a copy thereof, to obtain information from all personnel, education institutions, government agencies, to include The Department of Justice and The Youth Authority, companies corporations, worker’s compensation information, law enforcement agencies or individuals relation to my past activities, to supply any and all information concerning my background and release same from any liability resulting from providing such information. The information received may include, but is not limited to academic, job performance attendance, personal history, financial record history, disciplinary, driving (DMV or MVR) records, and criminal or civil records. I understand that the information released is for consideration of my employment application, resume and possible for the purpose of determining my qualifications for future assignments. I further hereby release any individual associated with the compilation of such information to include record custodians, directors, officer, agent, employees, if authorized representatives of the same, from any and all liability for damages of whatever kind of nature, which may at any time accrue to me on account of (1) reliance by such person on the information submitted in my employment applications: (2) reliance by such persons on the information obtained pursuant to this authorization: (3) compliance with, or any attempt to comply with, this authorization: and (4) termination of my employment based on information obtained after commencement thereof pursuant to validity of this authorization. If adverse action is taken based in whole or in part on the consumer report, we will provide to you a copy of the consumer report and summary of the consumer’s rights as prescribe by the FCRA. This report will not be used in violation of any federal or state laws and /or equal employment opportunity laws or regulations. I hereby certify that all the statements and answers set forth on this application form and documents signed are true and complete to the best of my knowledge, and I understand that if, subsequent to employment any of such statements and /or answer are found false or that information has been omitted, such false statement or omission will be just cause for termination of my employment. I understand that I have a right to receive a copy of any consumer report created as a result of this release form, by Liberty Alliance Inc. I have also stated clearly in the boxes listed below as to my desire to receive that report from this company to which I am applying up its completion. The investigative consumer-reporting agency preparing the report(s) is Liberty Alliance, Inc, 22707 La Palma Ave, Yorba Linda, CA 92887, telephone (800) 630-2880. Their files are available for review by appointment, by certified mail or telephonically with proper identification. Signature*PRINT FULL NAME(FIRST, MIDDLE & LAST NAME)* STREET ADDRESS (CITY, STATE & ZIP CODE)* Date* MM slash DD slash YYYY For purposes of gathering this information, I agree to supply the following information which may be required by law enforcement agencies and other entities for positive identification purposes in checking records. It is confidential and will not be used for any other purpose.DATE OF BIRTH* MM slash DD slash YYYY DRIVERS LICENSE NUMBER* STATE* SOCIAL SECURITY NUMBER* LAST NAME AS IT APPEARS ON LICENSE* * Yes, I would like a copy of any investigative consumer report that is conducted by Liberty Alliance, Inc. No, I do not need a copy of any investigative consumer report that is conducted by Liberty Alliance, Inc PRIVACY WAIVER AND PRE-EMPLOYMENT INVESTIGATION AUTHORIZATIONI declare under penalty of perjury that all statements I have made on this document, attachments hereto, or on my employment application, resume, or other supplementary materials are true and correct. I hereby authorize Infinity Staffing to verify the information given. To the full extent legally possible, I release Infinity Staffing, and its employees, as well as the organizations listed below and their employees from any claim or liability of any nature arising from such inquiry or the supplying of information thereto. I understand and agree that assignment and/or employment by Infinity Staffing is conditional upon the results of such inquiry and upon my execution of a proprietary information agreement. Additionally, I hereby authorize Infinity Staffing to obtain an Investigative Consumer Report to verify the data I have supplied. The Fair Credit Reporting Act (United States Code, Title 15.1681a-1681n) and the Investigative Consumer Reporting Agencies Act (California Civil Code 1786-1786.56) require that we advise you if an investigative consumer report is requested, which provides applicable information concerning character, general reputation, personal characteristics and credit history. If it is necessary to request an investigative consumer report, you will be notified with three days of the request as required. Upon your written request, additional information as to the nature and scope of the report, if one is made, will be provided. This only applies to investigative consumer reports as defined in the Fair Credit Reporting Act and the Investigative Consumer Reporting Act and the Investigative Consumer Reporting Agencies Act. Last Name* First* MI Drivers Lic. #* State* SS#* Residence History for the past seven years starting with current residenceStreet Address* Unit# City* State* Zip Code* Date: From* MM slash DD slash YYYY Date: To* MM slash DD slash YYYY Street Address Unit# City State Zip Code Date: From MM slash DD slash YYYY Date: To MM slash DD slash YYYY Street Address Unit# City State Zip Code Date: From MM slash DD slash YYYY Date: To MM slash DD slash YYYY Street Address Unit# City State Zip Code Date: From MM slash DD slash YYYY Date: To MM slash DD slash YYYY I have read and understand the authorizations and waivers given above. I also understand that any information obtained as a result of the pre-asssignment screening process may be shared with Infinity Staffing’s customers(s) for the purpose of determining my eleigibility for assignment and/or employment. I release and hold harmless Infinity Staffing’s customers(s) and their directors, officers, stockholders and employees for the above uses of my personal Information.Signature Infinity Staffing is an equal opportunity employerEmployment Application CertificationI hereby affirm that the information provided in this application, and any attached or submitted resume, is true and complete and that I have withheld no information that would, if disclosed, affect this application unfavorably. I understand that any false or misleading representations or omissions may disqualify me from further consideration for employment and may result in dismissal if discovered at a later date. Initial*Completion of this application does not assure me a position with Infinity Staffing Services Inc. I also understand that neither this application nor any other document constitutes a contract of employment for a specific term and that any employment relationship that may be established will be "at will" and may be terminated at any time with or without cause by myself or Infinity Staffing Services Inc. I also understand that no representative of Infinity Staffing Services Inc. has any authority to enter into any agreement for employment with me contrary to the foregoing. Initial*I hereby authorize Infinity Staffing Services Inc. to investigate all information pertinent to my application, including contacting current and former employers in order to determine my qualifications for employment. I hereby authorize all persons and organizations having information relevant to my application to provide said information to Infinity Staffing Services Inc. and I hereby agree to hold harmless Infinity Staffing Services Inc. and all those providing information to it from any liability arising from or as a result of the request for, the provision of or use of such information. I understand that any offer of employment may be rescinded or my employment may be terminated if my references are inadequate or unacceptable to Infinity Staffing Services Inc. or if I violate any of the provisions of this certification. Initial*I further understand that if hired by Infinity Staffing Services Inc., I must abide by all the company rules and regulations as communicated by Infinity Staffing Services Inc. employees and orientation materials which, with the exception of the "at will" employment policy, may be changed without notice at the discretion of Infinity Staffing Services Inc. I understand that (1) Infinity Staffing Services Inc. may require me to submit a drug and alcohol test prior to employment and a drug and alcohol test at any time during my employment, to the extent permitted by applicable law; and (2) Infinity Staffing Services Inc. may require me to consent to or authorize the disclosure of my criminal record and/ or consumer credit report prior to employment and at any time during my employment, to the extent permitted by law. Initial*I certify under penalty of perjury that all the information provided is true and correct to the best of my knowledge and that I have read, fully understood and agreed with the above statements. Signature*Date* Month Day Year Section BreakEmailThis field is for validation purposes and should be left unchanged.
