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Employment Application

Please Fully Complete This Application or your application will not be considered. If something doesn't apply to you, enter NA for Not Applicable.

If you would like to fill out an application in person, applications are only taken on Tuesday-Thursday from 9AM to 11AM



APPLICANT INFORMATION

Date of Application
Postion Applying for
First Name
Middle Initial
Last Name
The following Question is optional
Date Of Birth
Address
City, State
Zip Code
E-mail
Primary Phone Number
Secondary Phone Number
If a Cell Phone, Can you receive text messages?
Date Available for Work
Do you hold a valid driver’s license?
Do you have personal transportation?
If Yes, Please provide the make and model.
Have you ever been convicted of a crime?
If yes, please explain.
Do you currently have any charges pending against you?
If yes, please explain.
Can you pass a drug screening?
If no, please explain.
Have you ever failed or refused a drug and/or alcohol screening prior to this application?
If yes, please explain.

EDUCATION

Provide information for school attended below. Include name of school, location (Complete mailing address), Years completed, and Degree/Diploma.


High School
Did you graduate?
College
Did you graduate?
Please provide course of study, years completed, and/or diploma or degree.
Trade or Technical College
Did you complete your course of study?
Please provide course of study, years completed, and/or diploma or degree.

CERTIFICATIONS AND TRAINING

Are you OSHA certified?    Yes
   No
Are you TWIC certified?    Yes
   No
Are you Operator Qualification certified?    Yes
   No
Additional training, cerfications, activities, skills or accomplishments

MEDICAL INFORMATION


Do you have a disability or a medical condition that would prevent you from performing certain work duties?
If Yes, please explain specific work limitations.
Do you have allergic reactions to any insect bites or stings?
Do you have allergic reactions to Poison Ivy, Poison Oak, and/or Poison Sumac?
In the last 5 years, have you had any major medical illnesses?
If yes, please explain.
Have you ever received compensation for work related injuries? If Yes, Please explain.
If yes, please explain.

EMPLOYMENT EXPERIENCE

Please provide all information for the last 5 years of employment starting with the most recent.


1. Name of employer / Address / City, State, Zip Code / Phone number
Job Title
Dates Employed (From - To)
Hourly Rate/Salary (Starting - Final)
Supervisor
Reason for Leaving
May we contact your previous supervisor for a reference?    Yes
   No
2. Name of employer / Address / City, State, Zip Code / Phone number
Job Title
Dates Employed (From - To)
Hourly Rate/Salary (Starting - Final)
Supervisor
Reason for Leaving
May we contact your previous supervisor for a reference?    Yes
   No
3. Name of employer / Address / City, State, Zip Code / Phone number
Job Title
Dates Employed (From - To)
Hourly Rate/Salary (Starting - Final)
Supervisor
May we contact your previous supervisor for a reference?    Yes
   No

MILITARY SERVICE RECORD

Are you currently a member of the United States Armed Forces?
If Yes, Which branch are you a current member?
Were you previously a member of the United States Armed Forces?
Were you honorably discharged from your service?
Please provide the dates of duty served (From-To).
If hired, can you provide discharge documentation?

Out of Town Travel

If you work out of town, you will receive $25.00 a day per diem. The company pays for the room and provides transportation in company vehicles. There is absolutely no drinking during or after work hours when you are out of town. No visitors in rooms will be permitted. If any rules or policies are broken, that is grounds for termination. If you are let go and your only way home is a bus, Kelly's Industrial Services will pay for the ticket and deduct it from your check.


Are you able to work out of town for 5-10 days at a time if the job requires?    Yes
   No

APPLICATION STATEMENT

I certify that all information I have supplied in this application and in any other form, oral or written, is true, complete and accurate.  I understand that any information provided by me that is found to be false, incomplete, or misrepresented in any respect will be sufficient cause to (a) cancel further consideration of this application or (b) immediately discharge me from the employer’s service, whenever it is discovered. I expressly authorize, without reservation, Kelly’s Industrial Services, its representatives, employees, and / or agents to contact and obtain information from all references (personal and professional), employers, and public agencies, licensing authorities, and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume’, or job interview.  I also give permission for criminal / motor vehicle background checks.  I hereby waive any and all rights and claims I may have regarding Kelly’s Industrial Services, its representatives, employees and / or agents for seeking, gathering, and using such information in the employment process and all other persons, corporations, or organizations for furnishing such information about me, but understand my right to privacy shall be respected and the inquiries treated in confidence.  I understand Kelly’s Industrial Services does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law.  If I am hired, I understand that my employment will be at will.  This means that I am free to resign at any time, with or without cause and without prior notice, and Kelly’s Industrial Services reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law.  This application does not constitute an agreement or contract for employment for any specified period or definite duration.  I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied, oral or written agreements contrary to the foregoing express language are valid. I understand Kelly’s Industrial Services maintains a drug-free workplace and agree that maintenance of same is essential to the safety of the workplace and employees.  I promise to abide by the agency’s policies prohibiting the use or possession of drugs, alcohol, or any controlled substance, or the misuse of prescribed or over-the-counter medication on agency premises or while on duty.  I understand also that I may be tested for drugs, alcohol, or controlled substances if I am employed by Kelly’s Industrial Services If I am hired, I agree to comply with and be bound by Kelly’s Industrial Services safety and health rules and regulations, rules of conduct, and any other rule or procedure set forth by my employer. I understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 form in this regard.


I certify that I have read, fully understand, and accept all terms of the forgoing application statement
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