APPLICATION FOR EMPLOYMENT
GENERAL INFORMATION

Name:     Last, First, M.I.	Today’s Date:
Social Security #:	Referred by:
Permanent Address	Mailing Address (if different from permanent address)
Street:	Street:
City:   State: ? AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY	City: State: ? AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip Code:	Zip Code:
Home Phone:	In Case of Emergency:
Work Phone:	Contact Phone #1:
Pager/Beeper:	Contact Phone #2:
Mobile Phone:	Are you presently employed? Yes No May we contact your employer? Yes No
EDUCATION & TRAINING
College/University:	Degree Received:
City:   State: ? AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY	Date Received:
College/University:	Degree Received:
City:   State: ? AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY	Date Received:
Additional Professional Training
Institution:	Certificate Received:
City:   State: ? AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY	Date Received:
Employment History (List present or last job first)
Employer:	Position/Title:
Street Address:	Unit/Floor:
City/State/Zip:	Supervisor:
Dates Employed:	Telephone:
Reason for leaving:	Salary:
Employer:	Position/Title:
Street Address:	Unit/Floor:
City/State/Zip:	Supervisor:
Dates Employed:	Telephone:
Reason for leaving:	Salary:
Employer:	Position/Title:
Street Address:	Unit/Floor:
City/State/Zip:	Supervisor:
Dates Employed:	Telephone:
Reason for leaving:	Salary:
Employer:	Position/Title:
Street Address:	Unit/Floor:
City/State/Zip:	Supervisor:
Dates Employed:	Telephone:
Reason for leaving:	Salary:
Employer:	Position/Title:
Street Address:	Unit/Floor:
City/State/Zip:	Supervisor:
Dates Employed:	Telephone:
Reason for leaving:	Salary:
Military Experience Complete if you served in the United States Armed Forces Branch:    Active Duty From:   To:    Discharge other than honorable? No   Yes  If yes explain: . Describe your duties and special training: . [Disclosure of dishonorable or general discharge will not necessarily disqualify application or termination after employment.]
BACKGROUND Have you ever been convicted of a crime (misdemeanor or felony) other than a minor traffic violation, within the past seven (7) years? A conviction includes a plea, verdict, or finding of guilt regardless of whether sentence is imposed by the court. Yes No If yes:  Where?   When? Charge:   Sentence: (Disclosure of a criminal record will not necessarily disqualify you for employment; however, failure to disclose such information may result in disqualification of your application or termination after employment.) Do you have a valid driver’s license? Yes No License No.   State Expiration Date Has your driver’s license ever been suspended or revoked? Yes No Have you been cited for a traffic violation of any kind in the past five years? Yes No If yes, give details:
IMPORTANT: PLEASE READ CAREFULLY I certify that, to the best of my knowledge, all the information provided to Rapid Temps, Inc. hereforth, in this application packet and in any future communication, is true and complete. I understand that any misrepresentation, falsification or willful omission may result in a refusal of employment or dismissal after employment. I understand that a routine inquiry may be made during the processing of this application so as to acquire information concerning my employment record, education, licensure, certification, general reputation, character, background and work performance. I authorize educational institutions, employers, law enforcement authorities, organizations and individuals having relevant information concerning me to release such information. I release all concerned from any liability in connection therewith. Furthermore, I understand that if I am employed, my employment and compensation can be terminated, with or without cause or notice and at any time, at the option of either the company or myself. I understand that any employee manuals, handbooks or policy statements that effect employment are subject to change at any time and shall not be construed as a contract or a guarantee of continued employment. No representative of the company, other than the Chief Executive Officer of Rapid Temps, Inc. or one designated by the Chief Executive Officer, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing. I understand that many of the medical facilities served by Rapid Temps, Inc. require a physical examination and/or drug testing of personnel and that I may be asked to participate as a condition of placement. By submitting this Application electronically, I agree that the same constitutes my signature to this Application, and Rapid Temps, Inc. may rely upon the same as an electronic signature.