Employment Application List your name exactly as it appears on your Social Security Card to ensure proper tax credit. Full Name Last First MI Today s Date: List all names used in past Nickname SSN # - - Mailing Address Apt. # How did you hear about us? City State Zip Internet Phone ( ) Cell ( ) Message ( ) Newspaper Email: Text ok Friend Emergency contact? Phone ( ) Other Type of work desired Temporary Permanent Full-time Part-time OT ok? Pay Desired $ Salary Desired $ Over 18 years of age? Yes No Employment History Highest Degree: Certification: Name of institution From: To: Company Name: Supervisor's Name High School / GED Some College AA BA/BS M/PhD Trade School Other Reason for leaving Job Title: Company Address: Contact your supervisor? Yes No Ph: City State Zip Salary Starting: Ending: From: To: Company Name: Supervisor's Name Reason for leaving Job Title: Company Address: Contact your supervisor? Yes No Ph: City State Zip Salary Starting: Ending: From: To: Company Name: Supervisor's Name Reason for leaving Job Title: Company Address: Contact your supervisor? Yes No Ph: City State Zip Salary Starting: Ending: Other Employment Worked for or applied with TERRA in the past? Yes No Year: Worked with a staffing service before? Yes No Staffing Service Client Company Temporary Contact Job Duties Salary Other Known Languages: TERRA will not use any information provided to discriminate on the basis of race, color, religion, national origin, marital status, sex, sexual orientation, disability, age or any other classification protected by law.
Assembly / Production Office Use Light Industrial Office Use General Labor Office Use Assembler E G K C Drill Press E G K C General Labor E G K C Bander E G K C Cashier E G K C Guillotine Operator E G K C Bindery E G K C Cherry Picker Forklift E G K C Heavy Lifting E G K C Collator E G K C Commercial Housekeeping E G K C Heating/Vent/AC E G K C Machine Maintenance E G K C Commercial Painting E G K C Parking Lot Attendant E G K C Machine Repair E G K C Fabricator E G K C Plumbing E G K C Sheet Metal E G K C Factory Work E G K C Mover E G K C Sheet Operator E G K C Fiberglass E G K C Janitorial E G K C Lead Supervisor E G K C Food Service E G K C Landscaping E G K C Load & Unload E G K C Forklift Experience E G K C Laundry E G K C Injection Molding E G K C Heat Sealing E G K C Residential Housekeeping E G K C Inserting E G K C Labeling E G K C Painter E G K C Electronic Assembly Packaging E G K C Security E G K C Assembly-Electric E G K C Palletizer E G K C Schematics E G K C Electronics Test E G K C Picker/Packer E G K C Mailroom E G K C Final Assembly Electronics E G K C Shipping/Receiving E G K C Mill work E G K C Soldering E G K C Shrink Packaging E G K C Truck Driving E G K C Machine Shop Sorting E G K C Vending Machine E G K C CNC Lathe E G K C Stocking Clerk E G K C Warehouse E G K C CNC Operations E G K C Stock room E G K C Construction CNC Programming E G K C Tagging E G K C Blue Print Reading E G K C Manual Lathe E G K C Manufacturing Carpentry E G K C Machinist E G K C Inspection E G K C Construction Finishing E G K C Press Operations E G K C Inventory E G K C Framer E G K C Press Work E G K C Production Manager E G K C Grading E G K C Tool/Dye Maker E G K C Production Scheduler E G K C Extruder E G K C Tools Used Production work E G K C Woodworking E G K C Drill Press E G K C Quality Assurance E G K C Roofing E G K C Punch Press E G K C Quality Control E G K C Hazardous Materials E G K C Grinder E G K C Quality Testing E G K C Welding Hand Tools E G K C Scheduler/Expediter E G K C MIG Welder E G K C Nail Gun E G K C Supply Chain Spot Welder E G K C Sander E G K C Distribution E G K C Stick Welder E G K C Slitter Operator E G K C Supply Chain Analyst E G K C TIG Welder E G K C Licenses Supply Chain Management E G K C Certified Forklift E G K C Material Handler E G K C Commercial Driver E G K C Food Handler s Permit E G K C I certify that the statements I have provided on the application (and in my resume, if provided) are true, complete and correct and contain no errors, omissions, falsifications, misrepresentations, or misleading statements. If I am offered employment, I understand and agree that any error, omission, falsification, misrepresentation or misleading statement on the application or resume will be grounds for immediate termination regardless of when the error, omission, falsification, misrepresentation, misleading statement is discovered. I also understand my employment may be contingent upon successful completion of a drug test and background check. I understand that while on a temporary or temp-to-hire assignment I am an employee of TERRA Companies (TERRA Staffing Group) and as such must direct questions regarding attendance, compensation and benefits, or grievances to any TERRA Staffing Supervisor. Upon completion of each assignment and on a regular basis thereafter, I agree that if I do not continue to contact TERRA for work I may be considered unavailable and that I have terminated my employment with them. I authorize TERRA to contact my past employers for the purpose of verifying statements contained on my employment application. I release former employers and TERRA from any liability arising from disclosure of any information pertaining to me obtained during said investigation. I authorize TERRA to contact any person to verify any of the information I have provided. I hereby release from liability any person who provides any information about me to TERRA. I understand and agree that employment, if offered, will continue at the will of TERRA and myself and may be terminated at any time, for any reason, with or without notice or cause, by either me or TERRA. My employment with the company will remain terminable at will, not withstanding any other oral or written statements by the company, at or following my date of employment, except as provided in a separate writing, signed by the president of the company, which expressly provides for different termination provisions. I CERTIFY THAT I HAVE CAREFULLY READ THE IMPORTANT NOTICE SET FORTH ABOVE IN ITS ENTIRETY. Signature Date
I authorize my former employer to furnish TERRA Staffing Group with the information requested on this form and release that employer and TERRA Staffing Group from any and all claims and liabilities of any nature arising from such inquiry and investigation or the supplying of information for such investigation. Signature Company Employee Name SSN# Date REFERENCE REQUEST The above named employee has applied for employment through TERRA Staffing Group and has given you as a reference. Above is the signed authorization to release the information. We would appreciate you completing the information requested and returning this form to us. You may be assured any information you supply will be held in strictest confidence. Job Title Eligible for rehire? Yes No Dates worked: From: Performance Productivity Attitude Adaptability Attendance Punctuality To: Excellent Good Fair Poor Comments: Do you have any reason to believe the applicant may be dangerous, violent, abusive, or may engage in illegal, improper, discriminatory or harassing conduct at work? Yes No Signature Title Thank you for your cooperation. You may fax this form to us to the office checked below. TERRA Representative Tukwila Seattle Tacoma P 425.793.5460 P 206.405.3300 P 253.568.8545 Portland Everett Kirkland P 503.290.0039 P 425.355.7223 P 425.822.2929 FAX for all offices: 1.888.329.7599
Disclosure & Authorization for Employment Related Consumer Report and Drug Screening I understand that, as a condition of my consideration for employment, or as a condition of my continued employment, TERRA Staffing Group may obtain a consumer report that includes, but is not limited to, my employment and/or education verifications, social security verification, criminal and civil history, DMV records, any other public records and any other information bearing on my credit standing, character, general reputation, personal characteristics and trustworthiness. By signing the release below, I hereby authorize TERRA Staffing Group on behalf of TalentWise to contact any and all corporations, former employers, credit agencies, educational institutions, law enforcement agencies, city, state, county, and federal courts, military services to release information about my background as stated above. I release from all liability all persons, companies, schools supplying such information. I indemnify TERRA Staffing Group against all liability, which may result from making such requests. This release shall remain in effect for the length of my employment, if hired. I understand that, pursuant to the federal Fair Credit Reporting Act, TERRA Staffing Group will provide me with a copy of any such report if the information contained in such report is, in any way, to be used in making a decision regarding my fitness for employment. I further understand that such report will be made available to me prior to any such decision being made, along with the name and address of the reporting agency that produced the report. I believe to the best of my knowledge that all information I have provided both on the application and this authorization form is accurate, true and correct and that I fully understand the terms of this release. SIGNATURE: PRINT NAME (FIRST, MIDDLE, LAST): PRINT ANY OTHER NAMES USED: SOCIAL SECURITY #: BIRTHDATE (Mo/Day/Year): DRIVER'S LICENSE NUMBER & STATE (A DMV check will be completed only for jobs that require driving a company owned vehicle) # State ADDRESS: CITY/STATE/ZIP: EDUCATION VERIFICATION OTHER STATES: SCHOOL NAME: SCHOOL CITY: SCHOOL STATE: GRADUATION DATE (If applicable): FIELD OF STUDY: DEGREE RECEIVED: TalentWise, a consumer reporting agency, will obtain the report for the Company. PO Box 1048 Bothell, WA 98041 866-246-3570