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EQUAL OPPORTUNITY EMPLOYER: It is our policy to abide by all federal, state and local lawa prohobiting employment discrimination solely on the basis of a person‘s race,religious creed, color, national origin,citizenship status,ancestry, physical disability, mental disability, medical condition(including, but not limited to, cancer related or HIV related),pregnancy, childbirth,marital status, civil union or registered domestic partner status, sex, gender(including sex stereotyping and gender identity or expression), age, sexual orientation, military status (to include status as a Vietnam-era or special diabled veteran), genetic information, or any other protected status except where a reasonable bona fide occupational qualification exists
Please enter your Alignstaffing recruiter name (Enter N/A if not applicable): *
APPLICATION
PERSONAL
Last Name:*
Middle Initial:
First Name:*
E-mail:*
Alternative E-mail:
Other E-mail:
Street Address:*
City:*
State:*
Zip:*
Country:*
Home Phone:
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Mobile Phone:*
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Fax:
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Self-Identification Data Record The purpose of this Data Record is to comply with government record keeping, reporting, and other legal requirements. Periodic reports are made to the government on the following information. The information on this survey is voluntary and will be kept confidential.
Date of Birth:
SSN / SIN:
Gender:
Marital Status:
Veterans Status:
Ethnicity:
List any languages you speak, read or write fluently:
EMPLOYMENT DESIRED
Are you willing to relocate? Yes No
City:
State:
Country:
Type of Employment:(Select all that apply)
 Direct    Temp/Contract    Internship
Preferred Hours:
 Full Time    Part Time  
Salary Desired:
Location:
 On-Site  Off-Site
 No Preference
Availability:
Immediate
SKILLS
Skill Name:
Last Used:
Skill Level:
Yrs. Experience:
Skill Name:
Last Used:
Skill Level:
Yrs. Experience:
Skill Name:
Last Used:
Skill Level:
Yrs. Experience:
Skill Name:
Last Used:
Skill Level:
Yrs. Experience:
Skill Name:
Last Used:
Skill Level:
Yrs. Experience:
EDUCATION
Please list from the highest level of education/degree obtained
School Name/Program Name:*
Degree/Level Attained:*
Completion Date:*
 
School Name/Program Name:
Degree/Level Attained:
Completion Date:
 
School Name/Program Name:
Degree/Level Attained:
Completion Date:
 
School Name/Program Name:
Degree/Level Attained:
Completion Date:
 
School Name/Program Name:
Degree/Level Attained:
Completion Date:
 
Only list accredited colleges or universities by the Department of Education(DOE).The DOE Database with accredited institutions is located at http://ope.ed.gov/accreditation/.It is the applicant‘s responsibility to verify accreditation.
List any classes undertaken, degree/diploma, other education from an unaccredited college, as well as training, special skills or certificates/licenses that you possess related to the job:
Professional License/ Certification #: Professional License/ Certification Type: Issuing Agency: State Issued: Expiration Date:
Professional License/ Certification #: Professional License/ Certification Type: Issuing Agency: State Issued: Expiration Date:
PROFESSIONAL HISTORY
Please list from the most recent employment
Company Name:*
From:*
To:*
 
Position Title:*
Duties/Responsibilities:
City:*
State:*
Country:*
Supervisor:*
Supervisor‘s Phone Number:*
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May we contact:*
Company Name:*
From:*
To:*
Position Title:*
Duties/Responsibilities:
City:*
State:*
Country:*
Supervisor:*
Supervisor‘s Phone Number:*
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May we contact:*
Company Name:
From:
To:
Position Title:
Duties/Responsibilities:
City:
State:
Country:
Supervisor:
Supervisor‘s Phone Number:
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May we contact:
Company Name:
From:
To:
Position Title:
Duties/Responsibilities:
City:
State:
Country:
Supervisor:
Supervisor‘s Phone Number:
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May we contact:
Company Name:
From:
To:
Position Title:
Duties/Responsibilities:
City:
State:
Country:
Supervisor:
Supervisor‘s Phone Number:
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May we contact:
REFERENCES
Name & Position:*
Company Name:
Title:*
Telephone:*
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Mobile:
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Email Address:*
Relationship:* Professional Personal
Name & Position:*
Company Name:
Title:*
Telephone:*
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Mobile:
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Email Address:*
Relationship:* Professional Personal
Name & Position:*
Company Name:
Title:*
Telephone:*
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Mobile:
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Email Address:*
Relationship:* Professional Personal
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* I certify that the information given herein is true and complete to the best of my knowledge. I authorize to make such investigations and inquiries of the information provided herein, and other matters related hereto, as may be necessary. I hereby release employer, schools, and other persons, institutions or businesses from all liability in responding to inquiries in connection with my application. I understand that false or misleading information given in my application or during interviews may result in a refusal to hire, or discharge in the event of employment.
Signature:* Enter Full Name

Disclosure and Release
Align Staffing may obtain information about you from a consumer reporting agency for employment purposes. Thus, you may be the subject of a "consumer report" and/or an "investigative consumer report" which may include information about your character, general reputation, personal characteristics, and/or mode of living, and which can involve personal interviews with sources such as your neighbors, friends, or associates. These reports may be obtained at any time after receipt of your authorization and, if you are hired, throughout your employment. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your criminal history, education and/or employment history conducted by Align Staffing or another outside organization. The scope of this notice and authorization is all-encompassing, however, allowing Employer to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and, if you are hired, throughout the course of your employment to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report.
Acknowledgement And Authorization
I acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of "consumer reports" and/or "investigative consumer reports" at any time after receipt of this authorization and, if I am hired, throughout my employment. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Align Staffing or another outside organization acting on behalf of Employer, and/or Employer itself. I agree that a facsimile ("fax") or photographic copy of this Authorization shall be as valid as the original.
Applicant‘s Name:
First Name:
Middle Name:
Last Name(Maiden):
Signature:* Date:*
Date Of Birth:*
Social Security Number:*
Driver‘s License No:
State:
Professional License/Certificate Number:
State:
Profession:
School/University Name:
Degree/Diploma Type:
Date Received:
Current Address:*
No. Of Years at Current Address:
Previous Address within the Past 7 Years(Use back if additional space is needed):
Address:
City:
State:
Zip:
Address:
City:
State:
Zip: