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844-4-JET-FIX (844-453-8349)
CRS# 8BQR005D
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Personal Information
Provide full legal name as it appears on identification
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Last Name
First Name
Middle Initial
Home Phone
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Mobile Phone
Email Address
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Physical street address (do not use post office box)
Physical Street Address
Apartment #
City
State
Zip Code
Mailing address if different than physical address
Mailing Address
City
State
Zip Code
Employment Preferences
Shift(s) available to work
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1st (Day)
2nd (Evening)
3rd (Night)
Day(s) available to work
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Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Date Available
MM slash DD slash YYYY
Position Applying For
Minimum Pay Rate
How you heard about us
General Information
At least 18 years of age
*
Yes
No
Authorized to work in the United States
*
Yes
No
Reliable Transportation
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Yes
No
Education
Highest level of education completed
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Did not Graduate High School
High School Graduate/GED
Trade/Business School
College
Details on highest level of education completed
Name of School
City
State
Degree
Temporary Employment
Most recent temporary employment history
Agency Name
Company Name
Worksite Address
Position
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Employment
Most recent permanent employment history
Start Date
End Date
Company Name
Position
Reason for Leaving
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Most recent permanent employment history
Start Date
End Date
Company Name
Position
Reason for Leaving
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Most recent permanent employment history
Start Date
End Date
Company Name
Position
Reason for Leaving
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Americans with Disabilities Act
Empire Workforce Solutions complies with the Americans with Disabilities Act (ADA) and will provide reasonable accommodations whenever possible and necessary to perform the essential functions of the job. Employees may be subject to medical examinations and skill & agility testing as required for employment purposes.
Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation?
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Yes
No
Disclosures
True and Complete Information
I acknowledge that the information provided by me on this Employment Application is true and complete and I have not withheld any information that might adversely affect my opportunity for employment with Empire Workforce Solutions. I understand that it is grounds for immediate termination of employment if any information is found untrue, misleading or if I omit material facts.
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I acknowledge that the information provided by me on this Employment Application is true and complete and I have not withheld any information that might adversely affect my opportunity for employment with Empire Workforce Solutions. I understand that it is grounds for immediate termination of employment if any information is found untrue, misleading or if I omit material facts.
Applicant Signature
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Date
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