Application for Employment

Client Company

Date

PERSONAL INFORMATION

Name

Present Address

Home Phone

Cell Phone

Email Address

Date of Birth

Do you have the legal right to work in the U.S.?

Yes No

Position Applying For

Shift

Have you ever been employed by VL BEST PEO? lf so, when and where?

VL BEST PEO 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.

Are you Licensed/Certified?

Yes No

Name of License/Certification and issuing state

License/Certification Number

Has your License/Certification ever been revoked or suspended?

Yes No

lf yes, state reasons, date of revocation or suspension and date of reinstatement

lf hired, can you provide written evidence that you are authorized to work in the U.S. ?

Yes No

Are you eligible to perform the essential functions of the position for which you are applying either with or without reasonable accommodations?

Yes No

If necessary please describe what types of reasonable accommodations are needed

EMERGENCY CONTACT

PLEASE REVIEW THE FOLLOWING BEFORE SIGNING THIS APPLICATION FOR EMPLOYMENT

I authorize any representative of VL BEST PEO to investigate my background, including but not limited to, references, education and work history I authorize the above and any other individual or entity that may posses' information about my background to provide full disclosure without prior notice to me I release all of the above from any and all liability for damage of any kind which may at any time result to me because of compliance with this authorization to release information.

I understand that any falsification of this or any VL BEST PEO document may result in failure to receive an offer or if hired, dismissal from employment

I understand that any offer may be conditional on the successful completion of medical or drug testing

Applicant's Initials

Date

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

Name of Present or Last Employer

Address

State

Starting Date

City

Zip

Leaving Date

Job Title

May we contact your Supervisor?

Yes No

Name of Supervisor

Supervisor Title

Phone

Description of Work

Email Address

Reason for Leaving

Name of Present or Last Employer

Address

State

Starting Date

City

Zip

Leaving Date

Job Title

May we contact your Supervisor?

Yes No

Name of Supervisor

Supervisor Title

Phone

Description of Work

Email Address

Reason for Leaving

Name of Present or Last Employer

Address

State

Starting Date

City

Zip

Leaving Date

Job Title

May we contact your Supervisor?

Yes No

Name of Supervisor

Supervisor Title

Phone

Description of Work

Email Address

Reason for Leaving

REFERENCES: NAMES OF THREE PERSONS YOU ARE NOT RELATED TO, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR

Name

Address

Business

Year Acquainted

VL BEST PEO EMPLOYEE ACKNOWLEDGEMENT FOR WORKERS' COMPENSATION PROCEDURES
VL BEST PEO 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. VL BEST PEO 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.

Employee Name

Applicant's Initials

Date

Company Name