PERSONAL INFORMATION

Last Name:

First Name:

MI:    SS#:

Address:

APT:   City:   St:   Zip Code:

Address 2:

APT:   City:   St:   Zip Code:

Phone:	Alt. Phone:   Cell:
E-mail:	Pager:

IN CASE OF EMERGENCY (Name, Phone Number, Relationship)

Contact:

EDUCATION

High School:	Years attended:	Graduate:	Studied:
		Yes No
College:	Years attended:	Graduate:	Studied:
		Yes No
Trade, Business School:	Years attended:	Graduate:	Studied:
		Yes No

PERMANENT EMPLOYMENT HISTORY (Most recent position first)

From:	To:	Name of Employer, City, State:	Salary:	Position:	Reason for leaving:
From:	To:	Name of Employer, City, State:	Salary:	Position:	Reason for leaving:
From:	To:	Name of Employer, City, State:	Salary:	Position:	Reason for leaving:
From:	To:	Name of Employer, City, State:	Salary:	Position:	Reason for leaving:

TEMPORARY EMPLOYMENT HISTORY (Most recent position first)

From:	To:	Name of Employer, City, State:	Salary:	Position:	Reason for leaving:
From:	To:	Name of Employer, City, State:	Salary:	Position:	Reason for leaving:
From:	To:	Name of Employer, City, State:	Salary:	Position:	Reason for leaving:
From:	To:	Name of Employer, City, State:	Salary:	Position:	Reason for leaving:

REFERENCES

Name:	Address:	Business:	Years Known:
Name:	Address:	Business:	Years Known:
Name:	Address:	Business:	Years Known:

EQUIPMENT OWNED

Steel-tipped Shoes   Hard Hat   Safety Glasses   Ear Plugs   Tools

REFERRED BY

Telephone Book     Newspaper Which one(s)       Friend   Name

Walk in   Sign Company   Which one(s)   Other

QUESTIONS

Are you a U.S. Citizen?	Yes   No	Are you employed now?	Yes   No
Are you a permanent resident?	Yes   No	Do you need to give notice?	Yes   No
Are you over 18 years of age?	Yes   No	Do you have an answering  machine?	Yes   No
Foreign language capability?	Yes   No	Do you have Caller ID?	Yes   No

Type of work  Full Time Part Time Temp

Shifts Available  1st 2nd 3rd  Any

Days Available  Mon. Tues. Wed. Thurs.  Fri. Sat. Sun. ALL

Positions Desired

Salary Desired

Date you can start

Are you employed now?  Yes No	How far would you travel?  Miles Minutes	Transportation  Car Bus Own Car
Are you on:  Work Release Probation

Have you ever been convicted of a crime?	Yes  No	Explain:
Do you have any medical problems that restrict  you from performing any jobs?	Yes  No	Explain:
Are you able to lift? 25 - 30 - 35 - 40 - 45 - 50+LBS	Yes  No	Explain:
Are you collecting unemployment?	Yes  No	Explain:
How many weeks left on employment? (if yes above)	Yes  No	Explain:
Do you have any vacations, Doctors' appointments,  or court dates coming up that would prevent you  from working?	Yes  No	Explain:

WILL YOU ACCEPT ANY TYPE OF THESE ASSIGNMENTS?

Permanent	Yes   No	Short Term	Yes   No	Short Notice	Yes   No
Temp-Perm	Yes   No	Long Term	Yes   No	Summer	Yes   No

CHECK AREAS OF EXPERIENCE

	Warehouse		Skilled Trade		Maintenence		Construction		Automotive
	Picking   Packing   Shipping   Receiving   Inventory   Forklift   Security		Soldering   Assembly   Tech		Janitorial   Landscaping   Plumbing   Painting   Electrical   Mechanic   HVAC		Framer   Sheet Rock   Helper   Carpenter   Electrician   Plumber   Painter   Mason		Mechanic   Painting   Engine Rebuilds   Oil Changes   Tune Ups

	Machine Shop		Software		Financial		Sales		Office
	Welding   Milling   Drill Press   Lathe   CNC   Tool & Die   Machinist   Assembly		Word Perfect   Microsoft Word   Lotus Word Pro   Excel   Lotus 123   Quick Books   Quicken   Peachtree		Bookkeeper   Payroll   Accts. Rec.   Accts. Pay.   Collections   Accounting		Customer Service   Telemarketer		Front Office   Filing   Switchboard   Mail Room   Typing

	Secretary		Engineer		Computer
	Medical   Legal   Executive		Drafting   CAD Drafting   Design   Project   Civil   Electrical   Mechanical   Chemical   Architect		Data Entry   Data Base   Spread Sheets   Windows   Word Perfect   Programming   Networking

Authorization I understand that this application does not, by itself, create a contract of employment. I understand and agree that if hired, my employment is for no definite period of time and may be terminated without notice, for any reason or for no reason. I certify that the facts contained in this application shall be grounds for immediate dismissal. I authorize ERG Staffing to contact any person, school, employer, organization or reference I have listed. Responsibilities 1. You must call ERG Staffing ONE HOUR prior to your shift beginning if you need off from work or if you are going in late (after hours leave a message on our answering machine.) 2. You are only paid when an approved time card is received. Time cards MUST be dropped off from work or received in the mail by Monday 5:00PM (no faxing). If your card is received late you will be paid the following week. Injury and Accident Reporting 1. If you get hurt on job you are required to report the incident immediately to a Supervisor as well as ERG Staffing. You may only be treated by our medical company. (In New Jersey, The Medical Canter, Route 46 West, Budd Lake, NJ 07828 Phone: 973-691-0300 Fax: 973-691-3283. In Pennsylvania, Coordinated Health Systems, 296 East Brown Street, East Stroudsburg, PA 18301 Phone: 570-420-8880 Fax: 570-420-1704) If the incident is of a serious enough nature, requiring emergency treatment, please forward all bills to ERG Staffing. Failure to report the incident the day that it happens or failure to use our supplier will result in you being responsible for all costs. 2. You are required to take a drug test immediately after any injury, even if you were administered a pre employment drug test. The cost of the drug test will be paid by the employee. If you fail to ask and receive a drug test, or refuse a drug test, you will forfeit all rights to worker's compensation and will be responsible for all bills incurred. Drug Testing I, the undersigned, hereby authorize and give full consent to ERG Staffing and/or their medical company to send a specimen of my urine and/or blood to a laboratory for screening tests for the presence of illegal drugs, medication taken without a prescription and alcohol should a drug test be required by the company. The cost of the drug test will be paid for by the employee. I will hold all parties concerned harmless, meaning I will not sue nor hold responsible for any alleged harm to me or interfering with my obtaining a job or continuing employment for not submitting to the test or the results of the report of the test. This includes possible clerical or lab error. I have read this policy and understand it. Any questions I may have had have been fully answered. I understand that this is a legal and binding document. Criminal Records Release I, the undersigned, authorize ERG Staffing to be able to examine and and all criminal records or arrest on file with any state. I understand I am waiving my right to confidentiality concerning my criminal history. By signing below I acknowledge and understand my rights and duties listed above, this includes responsibilities, injuries, drug testing, and criminal records. Signature: X    Date: Inside the Wilkes-Barre Career Link 32 East Union Street, Wilkes-Barre, Pennsylvania 18711 Phone: 570-574-8029 Fax: 570-300-3301 E-mail: wilkesbarre@ergstaffing.com 170 Northampton Street Easton, PA 18042 Phone: 610-253-9700 Fax: 570-300-3301 E-mail: ergeaston@ergstaffing.com 1122 Hamilton Street Allentown, PA 18102 Phone: 610-770-1000 Fax: 570-300-3301 E-mail: allentown@ergstaffing.com 912 Main Street Stroudsburg, PA 18360 Phone: 570-476-4700 Fax: 570-300-3301 E-mail: ergstroudsburg@ergstaffing.com 817 Scranton-Carbondale Highway Scranton, PA 18508 Phone: 570-346-3400 Fax: 570-300-3301 E-mail: ergscranton@ergstaffing.com 330 South Church Street, Hazleton, PA 18201 Phone: 570-453-1001 Fax: 570-300-3301 E-mail: erghazleton@ergstaffing.com ERG Staffing is an equal opportunity employer dedicated to a policy of nondiscrimination in employment upon any basis, including race, color, creed, religion, age, sex, national origin, sexual orientation, martial status, military status, or the presence of any non-job related disabilities. Please keep in mind the questions contained in this application are not intended to be discriminatory.