Impact Staffing Application (do not use)

Date * Required
MM slash DD slash YYYY
Name * Required
First Middle Last
Nickname
Address * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone
Mobile Phone * Required
Additional Phone
Email * Required
How many hours per week would you like to work? * Required
How did you hear about us? * Required
Who referred you to Impact Staffing? * Required
Please tell us how you heard about Impact Staffing:

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Education
Please complete for highest level of education completed.
Name of Institution * Required
City and State * Required
Type of School * Required

For example, High School, College, Technical School, etc.
Degree Type

For example, Diploma, Bachelor’s Degree, Associate's Degree, etc.
Do you have a high school diploma? * Required
- Yes
- No
Do you have a GED? * Required
- Yes
- No
Military Experience
Have you ever served in the U.S. military? * Required
- Yes
- No
If yes, which branch? * Required
Start Date of Duty * Required
MM slash DD slash YYYY
End Date of Duty * Required
MM slash DD slash YYYY
Rank * Required
Title * Required
Duties * Required

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Additional Questions
Are you a United States citizen and/or do you have the legal right to remain and work in the United States? * Required
- Yes
- No
Are you under the age of 18? * Required
- Yes
- No
Do you have a work permit? * Required
- Yes
- No
Have you ever been convicted of a crime other than a traffic offense? * Required
- Yes
- No
Conviction of a crime is not an automatic bar to employment. All circumstances will be considered.
Please give conviction, date, and state in which offense occurred for all convictions other than traffic related: * Required

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Emergency Contact
Name * Required
First Last
Relationship * Required
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone * Required

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* Required
I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for Impact Staffing to hire me. If I am hired, I understand that either Impact Staffing or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of Impact Staffing has the authority to make any assurance to the contrary.
* Required
I acknowledge that consent to and successful completion of a substance abuse test upon request at any time is a condition of employment and continued employment with Impact Staffing. I hereby release Impact Staffing, its agents and any individuals who administer such tests or disclose the results of such tests from any and all liability and damages resulting from the administration of, disclosure of or reliance upon the results of any tests.
* Required
I attest with my signature below that I have given to Impact Staffing true and complete information on this application. No requested information has been concealed. I authorize Impact Staffing to contact references provided for employment reference checks. I hereby release Impact Staffing, its agents and the aforementioned who provide such information from any liability and damages regarding the provision or use of such information. If any information I have provided is untrue, or if I have concealed material information, I understand that this will constitute cause for the denial of employment or immediate dismissal.
Signature * Required
Date * Required
MM slash DD slash YYYY
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Impact Staffing Application (do not use)

Impact Staffing Application

Step 1 of 7

Hours Available

Education

Military Experience

Work Experience

Resume

Additional Questions

Emergency Contact