Test Results:________________________________________________________________________________________________________

Appointment Date / Time       /      /            :      Referred to QualStaff by:      

Position Applying for:      

Last Name First Name Middle Social Security # Home Phone #

                             

Street Address

     

City State Zip Code Email Address Cell Phone #

                           

Emergency Contact #1 Phone # Emergency Contact #2 Phone #

                       

Work Interest: (Mark an “X” in boxes that may apply)

F/T P/T Temporary Long Term Short Term Temp to Hire Direct Hire

Days Available: M T W Th F S Su Work Hours Available:      

Area City Preferred:       Commute: (Time or Miles)      

Available Start Date:       Comments:      

Pace: Fast Moderate Slow Style: Autonomous Interactive Team environment

Personal Strength:      

Hourly: $      Salary: $      (MINIMUM REQUIREMENTS)

High School Diploma/GED?   GPA     Trade School?   School Name:      

Professional Training/Certifications:      

College Degree?   GPA     College Attended:      

Graduate Degree?   In Progress?   GPA     College Attended:      

Updated 11/15/06

Interview: ______________________

Notes: (C) _____________________

Notes: (A) _____________________

Notes: (R) _____________________

Notes: (E) _____________________

Work Preferences:

Income Desired

Education (Enter “Y” for Yes and “N” for No)

Work History: (Please list your most recent employer first)

Employer’s Name & Address Your Position Title Direct Supervisor Phone # Reason For Leaving

                            

     

Your Position Responsibilities Your Salary (Hourly or Annually)

      $     

     

Interviewer’s Notes Dates of Employment:

From:       To:      

Employer’s Name & Address Your Position Title Direct Supervisor Phone # Reason For Leaving

                            

     

Your Position Responsibilities Your Salary (Hourly or Annually)

      $     

     

Interviewer’s Notes Dates of Employment:

From:       To:      

Employer’s Name & Address Your Position Title Direct Supervisor Phone # Reason For Leaving

                            

     

Your Position Responsibilities Your Salary (Hourly or Annually)

      $     

     

Interviewer’s Notes Dates of Employment:

From:       To:      

Reference’s Name Title Company Address/City/State/Zip Code Phone #

                             

                             

                             

Updated 11/15/06

1) Were you known to any employer, school or reference by another name? Yes No      

2) Are you at least 18 years of Age? Yes No

3) If employment is offered, can you submit verification of your legal right to work in the United States? Yes No

4) Have you ever been dismissed or forced to resign from any employment? Yes No

If yes, explain:     

5) Have you ever been dismissed or forced to resign from any employment for reasons that involved dishonesty

or breach of trust (including but not limited to shoplifting, discount abuse, cash handling, robbery, embezzlement,

theft, forgery, perjury, tax evasion, falsification of Company documents including timecards, etc)? Yes No

If yes, explain:     

6) Have you ever been convicted of a felony? (Do not identify any felony conviction for which the record has

been judicially ordered sealed, expunged, or statutorily eradicated). Yes No

If yes, explain:     

7) Have you ever been convicted of a misdemeanor? (Do not answer "yes" if the conviction record has been

judicially ordered sealed, expunged, or statutorily eradicated. Do not answer "yes" if probation for the conviction

was successfully completed or discharged and the case was judicially dismissed under Penal Code 1203.4. Do not

answer "yes" if your conviction was for a misdemeanor marijuana conviction and is more than 2 years old). Yes No

If yes, explain:      

8) Have you ever served on active duty in the US military service? (Exclude tours of active duty for training as a

reservist or guardsman.) Yes No

9) Have you ever been discharged from the armed service under other than honorable conditions? You may omit

any such discharge changed to honorable by a Discharge Review Board or similar authority. Yes No

If yes, explain:     

As an equal opportunity employer, QualStaff Resources does not discriminate in hiring or terms and conditions of employment because of an individual's race, color, sex, national origin, religion, age, disability, or any other legally protected basis. In consideration of my employment, I agree to conform to the rules and regulations of QualStaff Resources. I understand that, as a matter of Company policy, every aspect of my employment relationship with QualStaff Resources is on an at-will basis, meaning that I or QualStaff Resources may terminate my employment at any time, for any reason, with or without cause. As part of this at-will policy, I understand that QualStaff Resources expressly reserves its inherent authority to manage and control the business enterprise and to exercise its sole discretion to determine all issues pertaining to my employment as an Associate of QualStaff Resources. I further understand that any agreement, written or verbal, made contrary to the foregoing will not be valid without written authorization by the Director of Operations of QualStaff Resources and me.

Upon accepting employment, I will be provided with an Orientation Packet. I further acknowledge my understanding that the benefits, policies, and programs stated in the Orientation Packet are provided at Company discretion and may be changed or eliminated at any time, except the policy of at-will employment. If employed, it shall be my responsibility to familiarize myself and follow all Company policies and regulations relating to my employment. In accepting employment I acknowledge that the policies and benefits and other programs as set forth in these documents are not meant to infer or imply a contract of employment for a specified period between the Company and myself, or otherwise change the at-will nature of my employment.

I certify that the information contained in this application is correct to the best of my knowledge. I understand that falsification of any information on this application or a material omission is grounds for immediate dismissal whenever discovered. In considering my application for employment, I authorize the Company to verify the information set forth on this application and obtain any additional information relating to my background it may need to assess my suitability for employment. Accordingly, I authorize all persons, schools, companies, corporations, credit bureaus, and law enforcement agencies to supply the Company with information relating to my background and I do hereby release all such parties who provide information to the Company from any and all liability for damages that may result from furnishing the same.

Applicant Signature:       Date:      

Updated 11/15/06

Background Information

REFERENCE FORMTEMPORARY WORK HISTORY

Start Date

End Date

Job Title Client Supervisor’s Name & Title

                             

Pay Rate

Complete Assignment?If no, please provide reason.

Would you work on another assignment at client?

If no, please provide reason.

Staffing Service Recruiter

                             

Start Date

End Date

Job Title Client Supervisor’s Name & Title

                             

Pay Rate

Complete Assignment?If no, please provide reason.

Would you work on another assignment at client?

If no, please provide reason.

Staffing Service Recruiter

                             

Start Date

End Date

Job Title Client Supervisor’s Name & Title

                             

Pay Rate

Complete Assignment?If no, please provide reason.

Would you work on another assignment at client?

If no, please provide reason.

Staffing Service Recruiter

                             

Start Date

End Date

Job Title Client Supervisor’s Name & Title

                             

Pay Rate

Complete Assignment?If no, please provide reason.

Would you work on another assignment at client?

If no, please provide reason.

Staffing Service Recruiter

                             

Updated 11/15/06

NAME:       

SOCIAL SECURITY #:       

Skill Summary:          

Positions Held:   Positions Held (Cont):   Industry Exp (Cont):  

Applications Engineer, Senior        Programmer        e-commerce       

Applications Engineer, Staff        Product Data Manager        Education       

Applications Specialist        Program Administrator        Electronics Manufacturing       

Associate Engineer        Program Director        Entertainment       

Bus. Applications Engineer, Sr.        Programmer Analyst        Environmental Waste       

Bus. Applications Engineer, Staff        Project Engineer        Financial Institution       

CAD Administrator        Project Manager        Food Processing       

CAD/CAM Designer        QA Engineer        Furniture Manufacturing       

Client/Server Programmer        Regulatory Engineer        Government       

CNE/CNA        RF Engineer        Government Contracting       

Components Engineer, Senior        RF Technician        Healthcare       

Computer Systems Supt Analyst        Scheduler        Hotel/Motel       

Computer Technician        Senior Engineer        Human Resources       

Configuration Manager        Software Documenter        Industrial Manufacturing       

Consultant        Software Engineer        Information Technology       

Contract Administrator        Software Test Engineer        Insurance       

Data Analyst        Systems Administrator, Assoc.        Investment Company       

Database Programmer        Systems Administrator, Senior        Legal Services       

DBA/Database Administrator        Systems Analyst        Lumber & Wood Manufacturing       

Design Engineer        Systems Manager        Manufacturing       

Desktop Publisher        Systems Test Engineer        Medical       

Director of Manufacturing        Technical Editor        Metal Fabrication       

Document Control Manager        Technical Illustrator        Mining       

Drafter        Technical Support Analyst        Mortgage Companies       

e-commerce Administrator        Technical Support Manager        Motor Freight Transportation       

Editor        Technical Support Specialist        Non-Profit       

Electrical Engineer        Technical Writer        Oil & Gas       

Electronic Technician        UNIX Administrator        Paper Products Manufacturing       

Engineering Aide        VP Engineering        Pharmaceutical/Biotech       

Engineering Director        VP Quality Assurance        Plastic Manufacturing       

Engineering Intern        VP Technology        Printing & Publishing       

Engineering Manager        Web Developer        Public Accounting       

Functional Analyst        other:   Public Utility       

Graphic Artist                 Railroad Transportation       

Hardware Engineer                 Real Estate       

Help Desk                 Restaurant       

HRMS Analyst        Industry Experience:   Retail       

Information Systems Director        Advertising        Telecommunication       

Information Technology Director        Aerospace        Water Transportation       

Logistics Specialist        Agricultural        Wholesale Distribution       

Manufacturing Engineer        Air Transportation        other:  

Manufacturing Manager        Amusement Park                

Mechanical Designer        Apparel Manufacturing           

Mechanical Engineer        Architectural           

Multimedia Specialist        Automotive      

Updated 11/15/06

Network Administrator        Beverages      

Network Analyst        Communications      

Network Engineer        Computer Software      

PC Network Technician        Construction      

Planner        Credit Agencies      

Technical Experience:   Professional Certifications:   Networking/Op. Systems:  

AMPS        A+        ARCServe 6.0       

Analog IC Design        ASE        DOS       

Apache WebServer        ASNT        Groupwise       

AutoCAD        CE        LAN       

Avalon        Certified Internet Webmaster        Lantastics       

Baseband Chips        CNE/CNA        Linux       

Bipolar Technology        CSE        MacIntosh       

Board Level Design        Ericsson        Mail Server       

CDMA Technology        HyCurve        MS Back Office       

Cisco Routers        IBM        MS Back Office Small Bus.       

CMOS Technology        Informix        MS Exchange       

Control Systems        Linux Professional Institute        MS Exchange       

CORBA        Lucent Technologies        MS Networking       

CVS        MCSD        MS Proxy Server       

Educational Software        MCSE        MS SMS       

Ethernet TCP/IP        MCSE+I        MS SNA       

Firewalls        Microsoft        MS Windows 2000       

Frequency Synthesis        Network+        MS Windows 98       

FTP        Novell        MS Windows NT 3.51       

Gaming        other:   MS Windows NT 4.0       

GMP                 MVS       

GPS                 NetWare 3.0       

GSM                 Novell Netware       

HSPICE            OS/2       

IF            PC-Clone       

Image-Recognition            Peer-to-Peer       

Intralink        Foreign Languages:   Sun Solaris       

IPX        Cantonese        TCP/IP       

ISO 9000        Dutch        UNIX       

JEDEC Standards        German        WAN       

Just-In-Time (JIT) Systems        Hindi        Web Hosting       

KANBAN        Indonesian        other:  

Microbrowsers        Italian                

Mixed Signal ATE        Japanese                

MMI Programming        Korean                

MVS Build        Mandarin           

NFS        Portuguese        Hardware:  

NIS        Spanish        AS400       

Optic        Tagalog        Deck Alpha       

Perforce        Vietnamese        IBM & Compatibles       

PLL Design        Vietnamese        Macintosh       

Pro/E        other:   Main Frames       

QS 9000                 MiniComputers       

RDBMS                 other:  

RF                         

SNMP                    

Spectre                    

Updated 11/15/06

Telnet               

Virtual Reality Apps.               

Voice-Recognition               

Windows API               

Wireless Broadband               

other:          

                

Languages/Platforms:   Database Experience:   Spreadsheet Software:  

ASP        Access 2000        Excel 2000       

Ansii SQL        Access 97        Excel 97       

Assembler        Adabas        Lotus 123       

Avalon        Btrieve        Lotus 97       

Basic        DB2        Lotus DOS       

BB        Dbase III        QuatroPro 6.0       

C        Dbase IV        other:  

C++        FileMaker Pro 4.0                

COBOL        Foxpro                

Cold Fusion        Informix               

COM/COM+        Lotus Approach 97        Graphics/Presentations:  

CSP        MS Exchange Server        Corel Draw       

DB Reporter        MS Internet Info Server        Display Write IV       

DCOM        Oracle        First Publisher       

DHTML        OS/2 Server        FrameMaker       

FORTH        Paradox        Harvard Graphics       

Fortran        SQL Server 7.0        Illustrator       

Front Page 2000        Sybase        MacDraw       

Front Page 97        other:   MS Project Manager       

HDML                 PageMaker       

HTML                 Paint Shop       

Informix                PhotoShop       

JAVA        Word Processing Software:   PowerPoint 2000       

Javascript        AmiPro        PowerPoint 97       

Ladder Logic        Lotus WordPro        Quark       

MIPS        MS Word 2000        Visio       

MS FCL        MS Word 97        other:  

MS Visual InterDev        MS Works                

Natural        Word Perfect 7.0                

Netscape Composer        Word Perfect 8.0               

Oracle        other:   Misc Software:  

OS/2 Rexx                 McAfee Virus for Windows       

Pascal                 MS Outlook       

PL/1                 MS Project       

PLC            Norton Utilities       

QMF          other:  

Sequential Function Chart                    

Shell Scripts (csh, ksh, perl, etc.)                    

SPARC        Job Search Engines:   Resume Postings:  

SQL        list below primary job search sites:   list below where you post your resume:  

Structured Text                         

Visual Basic 5.0 and above                         

Visual Basic for Applications                         

Visual C                         

Visual C++                         

Updated 11/15/06

Visual Fox Pro                         

Visual J++               

Visual Java               

Winsock               

WML               

XML               

XSL              

other:          

                

Updated 11/15/06