Last Name:
First Name:
Middle Initial
Other name(s) known by
Driver's License Number and state where issued
Are you less than 18 years of age?
Are you eligible for employment in the U.S.? (Proof of U.S. citizenship / immigration status will be required if hired)
Have you been convicted of a felony in the past seven years? If yes, please explain. (A conviction will not necessarily disqualify you for consideration)
Address:
Apt No.
City
State
Zip Code
Nearest intersection near home address.
How long at this address?
Do you have reliable transportation to and from work?
Home Phone Number
Cell Number
Emergency Contact
Emergency Phone Number
Email Address:
Referral Source
Are you currently employed by another staffing agency?
EMPLOYMENT DESIRED
Position 1:
Position 2:
Position 3:
Hours Available
MON
TUE
WED
THURS
FRI
SAT
SUN
EDUCATION
High School (name & address)
Years Completed
Graduate?
Degree Received
Trade School (name & address)
Years Completed
Graduate?
Degree Received
College (name & address)
Years Completed
Graduate?
Degree Received
MILITARY RECORD
Branch of Service
Rank
Discharge Date
CURRENT EMPLOYER
Employer Name & Address
From
To
Position(s) Held
Reason for leaving
Start ($/hr)
End ($/hr)
Supervisor's Name & Title
Phone Number
May we contact him / her?
PREVIOUS EMPLOYER
Employer's Name & Address
From
To
Position(s) Held
Reason for Leaving
Start ($/hr)
End ($/hr)
Supervisor's Name & Title
Phone Number
May we contact him / her?
PREVIOUS EMPLOYER
Employer's Name & Address
From
To
Position(s) Held
Reason for Leaving
Start ($/hr)
End ($/hr)
Supervisor's Name & Title
Phone Number
May we contact him / her?
PREVIOUS EMPLOYER
Employer's Name & Address
From
To
Position(s) Held
Reason for Leaving
Start ($/hr)
End ($/hr)
Supervisor's Name & Title
Phone Number
May we contact him / her?
PERSONAL OR PROFESSIONAL REFERENCES
Name
Occupation
Daytime Phone
Years Known
Name
Occupation
Daytime Phone
Years Known
Name
Occupation
Daytime Phone
Years Known
SKILLS AND EXPERIENCE Please indicate the amount of experience you have in the positions listed below. If none, please leave blank.
Other Skills (please list below)
Other Skills / Additional Comments
Uniform Information (check all that you own) Black Pants (dressy)
Black Shoes (comfortable)

I hereby authorize Host Staff to thoroughly investigate my background, references, employment record, criminal record, and other matters related to my suitability for employment. I authorize persons, schools, my current employer (if applicable), and previous employers and organizations contacted by Host Staff to provide relevant information regarding my current and / or previous employment and I release all persons, schools, employers of any and all claims for providing such information. I understand that misrepresentation or omission of facts may result in rejection of this application, or if hired, discipline up to and including dismissal.

I understand that filling out this form does not indicate there is a position open and does not obligate Host Staff to hire me and that my employment is at will, which means that it is for no specified period of time and may be terminated by me or Host Staff at any time without prior notice for any reason.

I also understand that (1) Host Staff has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment, (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such contract.


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