Applicant Form - Provide Staff

Name*

First Last

Notes

Address*

Street Address Address Line 2 City State ZIP Code

Social Security Number*

Home Phone*

Cell Phone*

Email*

Enter Email Confirm Email

What is your current work Status?*

Working Full Time
Working Part Time
Unemployed
Looking to advance my career
Looking to make more money
Looking for my first job in a warehouse/ production setting.

How did you hear about Provide Staff?*

Are you related to any current Provide Staffing employees?*

If yes, please explain your relationship. If no put N/A.

Were you referred to Provide Staff?

If yes, please enter their name here.

Have you ever applied with Provide Staffing Services before?*

Yes
No

Please check all methods Provide Staff may contact you for all employment related issues/ opportunities.*

Home Phone Calls
Cell Phone Calls
Text Messages
E-mail
All Methods

What office are you applying for?*

Arkansas
Irving, TX - DFW
Memphis, TN
Mississippi
Missouri

What areas are you available to work in?*

West Memphis, AR
South Memphis (3rd Street)
Downtown
Midtown
North Memphis (Chelsea - Hollywood)
East Memphis (Our Office)
Southaven
Olive Branch
Byhalia

For Memphis office applicants only

Where are you applying?*

Home
Library
Personal Phone
In a Provide Staff Office
Workforce/ Unemployment Office

Availability

Are you authorized to work in the United States?*

Yes
No

Are you 18 years old or older?*

Yes
No

Can you work overtime?*

Yes
No
Must have at least 24 hours notice

Do you have reliable transportation?*

Yes
No

Most of our positions require standing and moving on your feet for 8-12 hours a day. Is this OK?*

Yes
No
I would need reasonable accommodations

I am comfortable lifting ____ pounds, by myself.*

Are you able to work in a facility that does not have centralized heating or cooling?*

Yes
I would need centralized heating.
I would need centralized cooling.
I would need both centralized heating and cooling.

Some of our positions may require you to work closely with numerous people at a fast pace, in order to meet production goals. Are you comfortable working closely in a fast paced environment?*

Yes
I can not work with people within arms length.
I can work with people within 5 feet of me.
I need more than 5 feet of space around me.

How many times a month is it acceptable to miss work?*

Other (Acceptable Days Missed):

If you choose to use the other box, please explain.

Do you have any appointments or court dates in the first 30 days, of your available start date?*

If yes please list. If no put N/A.

What shifts can you work?*

1st
2nd
3rd

Position Applying For?*

Forklift
Warehouse
Clerical
Other

Other Position Applying For:

If other was selected, please provide more detail here.

How far are you willing to travel to work?*

When are you available to start?*

What is your desired hourly wage?*

Education

What high school did you attend?*

What is the last grade you completed?*

9th
10th
11th
12th
Went to College

Did you receive a High School diploma or GED?*

Diploma
GED
Neither

Did you attend college? Did you graduate?*

What was your major/ minor?

Do you have any special skills or trades?*

If yes please explain. If no put N/A.

Emergency Contacts

Emergency Contact Name (#1):*

Emergency Contact Phone (#1):*

Emergency Contact Name (#2):

Emergency Contact Phone (#2):

Work Experience

General*

List other Warehouse Experience?

If other was selected, please provide more detail here.

Are you forklift Certified?*

If yes, list expiration date. If no put N/A.

Forklift:*

List other Forklift Experience?

If other was selected, please provide more detail here.

Clerical*

List other Clerical Experience?

If other was selected, please provide more detail here.

Past Employment

List your last 3 employers, starting with the most current first.

Name of Company (#1)*

Permanent or Staffing Agency? (#1)*

Permanent
Agency

Name of Agency (#1):

Company Address (#1):*

Agency Street Address (#1) Agency City (#1) Agency State (#1)

Position (#1):*

Pay (#1):*

May we contact this employer? (#1)*

YES
NO

Start Date (#1):*

End Date (#1):*

Reason for Leaving? (#1)*

Name of Company (#2)

Permanent or Staffing Agency? (#2)

Permanent
Agency

Name of Agency (#2):

Address (#2):

Agency Street Address (#2) Agency City (#2) Agency State (#2)

Position (#2):

Pay (#2):

May we contact this employer? (#2)

YES
NO

Start Date (#2):

End Date (#2):

Reason for Leaving? (#2)

Name of Company (#3)

Permanent or Staffing Agency? (#3)

Permanent
Agency

Name of Agency (#3):

Address (#3):

Agency Street Address (#3) Agency City (#3) Agency State (#3)

Position (#3):

Pay (#3):

May we contact this employer? (#3)

YES
NO

Start Date (#3):

End Date (#3):

Reason for Leaving? (#3)

Have you ever been discharged or asked to resign from any job? If yes, please explain. If no, put N/A.*

Please list all the companies you have worked that were not included in your 3 most current jobs.*

Closing Summary

Equal Opportunity Employer: Provide Staffing Services, LLC, is an Equal Opportunity Employer. Employment offers are made on the basis of qualifications, without regard to race, sex, religion, national or ethnic origin, disability, age, veteran or military status, sexual orientation, or marital status. I, __________________________, understand that neither the completion of this application, nor any other part of my consideration for employment establishes any obligation for Provide Staffing Services, LLC to hire me. If I am hired, I understand that Provide Staffing Services LLC, or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of Provide Staffing Services, LLC, has the authority to make any assurance to the contrary. I attest with my signature below that I have given to Provide Staffing Services, LLC, true and complete information on this application. No requested information has been concealed. I authorized Provide Staffing Services, LLC, to contact references provided for pre-employment reference checks. If any information I have provided is untrue, or if I have concealed material information, I understand that this will constitute cause for the denial of employment, or immediate dismissal, if on a job assignment already. I acknowledge that I am not eligible to receive benefits offered by Provide Staffing Services, LLC clients to their employees. I also understand that any offer of employment from Provide Staffing Services, LLC is conditional on Provide Staffing Services, LLC receiving satisfactory responses to reference request, background check, passing a drug screen, and providing satisfactory proof of my identity and legal authority to work in the United States. I understand that I may not be eligible for full time hiring at a Provide Staffing Services, LLC client unless I have worked 90 days or 720 hours as a Provide Staffing Services, LLC associate. If I accept full time employment and have not met these requirements, I agree to compensate Provide Staffing Services, LLC monetarily the difference in the hours or days not met. Under no circumstances is full time employment guaranteed when being offered an assignment with a Provide Staffing Services, LLC client. I consent to a pre-employment test to detect the use of controlled substances, alcohol, or prescription medication without a prescription. I understand that I may be required to drug screening post- accident for illegal drugs and or controlled substances. If I refuse to sign the consent, fail to take a pre-employment or accident related drug screen, or fail any portion of the test, I will not be considered for employment, or if employed, I will be terminated. I understand and agree that Provide Staffing Services, LLC may release the results of my drug screening to the State Unemployment Department if a claim for unemployment insurance is filed by me or on my behalf. I agree to hold all parties harmless and not sue in connection with any aspect of drug screen testing or its effect on my employment status. I understand that if I have any questions about the meaning of the provisions in this authorization and consent or the drug screens, they will be answered on request.

Signature*

Date Signed*

Time Signed*

: HH

MM

Resume

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2 Forms of I.D.

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Comments

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