Please fill out the following information to submit your application to Staffing Services.


Job Type Preferred:
Job Location Preferred:

Social Security Number :
Last Name:
First Name:
Middle Initial :
Street Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Emergency Contact Name:
Emergency Contact Phone:
Email Address:

Date available to begin work:
Minimum Rate per Hour:
Preferred Shift:	First Shift Second Shift Third Shift
How did you hear about Staffing Services?
What days are you available to work?
What hours are you available to work?
Do you have transportation available?	Yes No
Please select the type of assignment you prefer: (You may select more than one option)	Same Day Assignment Long-term Assignment Available Part-time
Which of the following do you prefer: (You may select more than one option)	Full Time Temp to Hire Direct Hire
Which location would you be willing to commute to? (You may select more than on option)	Lincoln Omaha Crete

Have you ever applied with a temporary service before?	Yes No
If you answered yes, please list which firm(s):
Have you ever filed an application with us before?	Yes No
Have you been employed with us before?	Yes No
Are you currently employed?	Yes No
Are you currently on a lay off and subject to recall?	Yes No
Can you travel if the job requires it?	Yes No
Do you have a valid driver's license?	Yes No
Are you willing to take a pre-employment drug test?	Yes No
Please list the languages in which you are fluent:

Have you ever been convicted of or plead guilty to any crimial offense, (including DUI and including pleas held in abeyance or under a deferral program) exept for minor traffic violations?	Yes No
If you answered 'Yes' to the previous question, please describe in the space provided:
Please list your prior education:
Please list your employment history:
Please list your references and their phone numbers in the spaces provided: