English Form

Application for Employment

PERSONAL INFORMATION

Name

Present Address

YOUR STAFFING FIRM OFFERS EQUAL EMPLOYMENT OPPORTUNITIES REGARDLESS OF SEX, AGE, RACE, COLOR, RELIGIOUS CREED, NATIONAL ORIGIN, ANCESTRY, MEDICAL STATUS, MEDICAL CONDITION, PHYSICAL OR MENTAL DISABILITY, PREGNANCY OR SEXUAL ORIENTATION.

EMERGENCY CONTACT

PLEASE REVIEW THE FOLLOWING BEFORE SIGNING THIS APPLICATION FOR EMPLOYMENT

FORMER EMPLOYERS (LIST BELOW THE LAST THREE EMPLOYERS, STARTING WITH THE MOST RECENT ONE)


REFERENCES: NAMES OF THREE PERSONS YOU ARE NOT RELATED TO, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR
YOUR STAFFING FIRM EMPLOYEE ACKNOWLEDGEMENT FOR WORKERS' COMPENSATION PROCEDURES

Your Staffing Firm is involved with a wide variety of Medical Providers for Workers' Compensation. This helps provide the most timely and suitable, quality medical care in the event of an injury on the job. Your Staffing Firm requires post-accident drug testing. After an employee is clinically tested and the results are positive, the employee will be terminated.

The following procedures must be followed for all work related injuries and illnesses.

1) Report promptly all work-related injuries to your supervisor. Your supervisor will direct you to the nearest authorized Occupation Medical Provider.
2) If it is a medical emergency, get medical care immediately, then notify your supervisor.
3) Complete a Workers' Compensation packet within 24 hours of the time of injury, including the Injury Incident Report and Post - Accident Drug Testing Policy,
4) Take post injury drug screen at the clinic.
5) After treatment, you must bring back to your supervisor the paperwork given to you at the clinic. This will normally include the Doctor's Report with any Work Restrictions and Documentation that you did take a Drug Test. Understand that in almost every case "Modified Work Will be Offered to You."

Please sign below to indicate that you have read and understand the procedures to follow in the event of an injury.

Corporate Office

Brea

60 Pointe Dr. #100 Brea, CA 92821

West Covina

549 S. California Ave West Covina, CA 91790

Lynwood

10919 Atlantic Ave Lynwood, CA 90262

Lancaster

2155 W. Longhorn Drive Lancaster, Tx 75134

Whittier

14714 Whittier Blvd Whittier, CA 90603

Ontario

1035 S. Millken Ave Suite A Ontario, CA 91761

Carson

860 E. Carson St #114 Carson, CA 90745