Qservices Employment Application(6)

7/27/2019 Qservices Employment Application(6)

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INTRODUCTORY INFORMATION:

Name: ____________________________________________________ Date: _______________________

Address: _______________________________________________________________________________________

City: _____________________ State: _______ Zip: __________ Phone: _________________

Email: _____________________

APPLICANT QUESTIONS:

Job location applying at: _________________________

Are you aware of any engagements that will interfere with your work in the next 12 months? __Yes __No

If Yes, please explain: _____________________________________________________________________________

Position applying for: _______________ Wage desired: ___________ Date Available: _________

If hired, can you provide documents required to establish your eligibility to work in the U.S.? __Yes __No

Do you meet our states minimum age requirement for work? __Yes __No

How were you referred to Q Services & Technologies?__________________________________________________

Do you have any relatives that work for the company? If yes, please list below: __ Yes __ No

Name Position Relationship_

1.___________________________________________________________________________________________

2.___________________________________________________________________________________________

Have you previously worked for the company? __Yes __No

Have you ever been convicted of a criminal offense? __Yes __No

If yes, please explain in detail below and include the date of final disposition of the case and the nature of the offense.

This information will not necessarily disqualify you from employment but false or misleading information will. Factors

such as age and time of the offense, seriousness and nature of the violation, and rehabilitation will be taken into account.

________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

MILITARY EXPERIENCE:

Have you ever been in the military? __Yes __No

If Yes, Please list experience and special education received in the military:

Branch of Service: _________________________________ From: __________ To: ___________

Rank/Type of Service: ____________________________________________________________________________

Job-Related Training/Experience: ____________________________________________________________________


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RECORD OF EMPLOYMENT:

List positions starting with most recent; do not go back more than ten (10) years:-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Employer: _____________________________________________ Telephone: _______________________________________

Address: ______________________________________________________________________________________________

Position Title: __________________________________ Supervisor: _______________________________________________

Start Date: _____________ Date Left: _________________ Beginning Salary: _____________ Ending Salary: ______________

Duties: ___________________________________________________________________________________________________

Reason for Leaving: ________________________________________________________________________________________-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------


Address: ______________________________________________________________________________________________



Duties: ___________________________________________________________________________________________________



Address: ______________________________________________________________________________________________



Duties: ___________________________________________________________________________________________________



Address: ______________________________________________________________________________________________


Start Date: _____________ Date Left: _________________ Beginning Salary: _____________ Ending Salary: ______________Duties: ___________________________________________________________________________________________________


STATEMENT (Please read this statement carefully before signing this application):

I understand that employment with Q SERVICES & TECHNOLOGIES, INC. (the Organization) is at will and that I am free to resign

at any time. Q SERVICES & TECHNOLOGIES, INC. reserves the right to terminate my employment at any time, with or without

just cause, and without any prior notice. I also understand that no representative of the company has the authority to make any

assurances to the contrary.

I authorize the Organization to conduct a thorough background investigation of my work and personal history, and verify all data

given on this application and during interviews. I hereby release the Organization, and its representatives or agents, from any liability

that might result from such an investigation. I authorize all individuals and firms named to provide any requested information andrelease them from all liability for providing the requested information.

I understand that the Organization may require the successful completion of a drug and/or alcohol test as a condition of employment.

I understand and authorize Q SERVICES & TECHNOLOGIES, INC. to obtain a background check on me to include criminal records

check at any time during the application phase or during my employment with them.

I understand this application will be active for a period of 30 days; after that time, if I wish to be considered for employment, I

must submit a new application. I certify that all the statements in this completed application are true and understand that any

falsification or willful omission shall be sufficient cause for dismissal or refusal to hire.

Signature of Applicant: ___________________________________ Date Signed: ________________________


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EQUAL EMPLOYMENT OPPORTUNITY (EEO)

VOLUNTARY SELF-IDENTIFICATON FORM

Qualified applicants are considered for employment without regard to race, religion, sex, national origin, age, marital status, sexual

orientation, veteran status, disability, or other protected characteristic.

The employer is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws

and regulations. In order to comply with these laws, the employer invites employees to voluntarily self-identify their race or ethnicity.

Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information

obtained will be kept confidential and may only be used in accordance with the provisions of applicable laws, executive orders, andregulations, including those that require the information to be summarized and reported to the federal government for civil rightsenforcement. When reported, data will not identify any specific individual.

This detachable form will be kept in a confidential file separate from your application for employment.

Name (Last, First, MI): ___________________________________________________________________

Street Address: ___________________________________________________________________

City, State, Zip Code: ___________________________________________________________________

Position Applied For: ________________________ Date Applied: ________________________

Gender Identification (check one)

____ Female ____ Male

Race/Ethnic Identification (check one):

____ Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or

origin regardless of race.

If you did not check Hispanic or Latino above, please select one of the following race/ethnic identifications.

____ White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or

North Africa.

____ Blackor African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa.

____ Native Hawaiian or Other Pacific Islander(Not Hispanic or Latino) - A person having origins in any of the peoples of

Hawaii, Guam, Samoa, or other Pacific Islands.

____ Asian(Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia, or

the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands,

Thailand, and Vietnam.

____ American Indian or Alaska Native (Not Hispanic or Latino) - A person having origins in any of the original peoples of

North and South America (including Central America), and who maintain tribal affiliation or community attachment.

____ Two or More Races (Not Hispanic or Latino) - All persons who identify with more than one of the above five races.

_____ Decline self-identification

_________________________________________________ __________________

Applicants Signature Date

Documents

Qservices Employment Application(6)