Application for Employment

Burnham Staffing LLC is an equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law.Should an applicant need reasonable accommodation in the application process, he or she should contact a company representative.

Applicant Information

First Name *

Last Name *

Date of Application * +

All Applicants MUST be 18 years of age or older, can you meet these requirements? *

Yes

No

Date of Birth: * +

Address 1 *

City *

State *

Zip Code *

Home Phone Number: *

Mobile Phone Number:

Email Address

Position(s) Applying for: *

Emergency Contact *

	Please list emergency contact name, phone number, Relationship
Name:	Please list emergency contact name, phone number, Relationship
Phone Number:	Please list emergency contact name, phone number, Relationship
Relationship:	Please list emergency contact name, phone number, Relationship

Have you ever been convicted of a felony? *

Yes

No

If yes, please explain.

Are you legally authorized to work in the United States? *

Yes

No

Availability

Days Available *

When you are available to start work? * +

Type of work desired: *

Full time

Part time

Shift preference: *

1st shift

2nd shift

3rd shift

Minimum Pay Desired: *

Personal Information:

Have you ever applied or worked for Burnham Staffing? *

Yes

No

If yes, please provide date: +

How did you hear about us? *

Will you consent to a mandatory controlled substance test? *

Yes

No

Do you have any condition which would require job accommodations? *

Yes

No

If yes, please describe accommodations required below.

Have you ever been convicted of a criminal offense (felony or misdemeanor)? *

Yes

No

If yes, please state the nature of the crime(s), when and where convicted and disposition of the case:

	(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense.The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)
Nature of Crime(s):	(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense.The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)
Date Convicted:	(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense.The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)
What County:	(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense.The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)

Job Skills/Qualifications

Please list below the skills and qualifications you possess for the position for which you are applying:

(Note: Burnham Staffing complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. It is possible that a hire may be tested on skill/agility and may be subject to a medical examination conducted by a medical professional. )

Education and Training

Do you have a high school diploma or GED? *

Yes

No

Name of High school or Educational Facility:

	(Please note, this does not disqualify any applicant from obtaining employment with Burnham Staffing.
Name of School:	(Please note, this does not disqualify any applicant from obtaining employment with Burnham Staffing.
Year completed:	(Please note, this does not disqualify any applicant from obtaining employment with Burnham Staffing.
Degree Earned:	(Please note, this does not disqualify any applicant from obtaining employment with Burnham Staffing.

Do you have Vocational or Specialized Training?

	If yes, please provide information
School Name:	If yes, please provide information
Year Graduated:	If yes, please provide information
Degree Earned:	If yes, please provide information

Military:

Are you a member of the Armed Services? *

Yes

No

If yes, What branch of the military did you enlist?

What was your military rank when discharged?

What military skills do you possess that would be an asset for this position?

To all that have served, We Thank You for your service.

Employment History:

Employer 1

Company Name *

Address

Phone Number

Start Date +

End Date +

Position *

Salary

Supervisor/Manager

Reason for Leaving

May we contact? *

Yes

No

Employer 2

Company Name

Address

Phone Number

Start Date +

End Date +

Position

Salary

Supervisor/Manager

Reason for Leaving

May we contact?

Yes

No

Employer 3

Company Name

Address

Phone Number

Start Date +

End Date +

Position

Salary

Supervisor/Manager

Reason for Leaving

May we contact?

Yes

No

References

Personal Reference

Name *

Relationship

Phone Number *

Professional Reference

Name

Title

Phone Number

Additional Skills

List any additional skills that you would like to mention.

Please submit a copy of your resume.

Application Disclosure (Please Read)

AT-WILL EMPLOYMENT:

The relationship between you and the Burnham Staffing is referred to as "employment at will." This means

that your employment can be terminated at any time for any reason, with or without cause, with or

without notice, by you or Burnham Staffing. No representative of Burnham Staffing has authority to enter into

any agreement contrary to the foregoing "employment at will" relationship. You understand that your

employment is "at will," and that you acknowledge that no oral or written statements or representations

regarding your employment can alter your at-will employment status, except for a written statement

signed by you and either our Executive Vice-President/Chief Operations Officer or the Company's

President.

NATIONAL BACKGROUND SCREENING:

A national background screening will be conducted upon offer of employment. A one-time $35.00 fee will be deducted from your first paycheck.

By signing this application, you are agreeing to the terms.

When signing this application, you acknowlege and agree that the information provided on this form, is true and correct to the best of your ability.

Print Name: *

Date: * +

Applicant Signature: *

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