O M Part-Time

**** **** ***, *** ***, Wynnewood, PA *****

w w w . p a c e r s t a f f i n g . c o m 215 - 6 6 6 - 0 0 1 2 i n f o @ p a c e r s t a f f i n g . c o m P A C E R S T A F F I N G L L C

EMPLOY MEN T A PPLI C A TI ON

Pacer Staffing LLC is a drug-free workplace. We are an Equal Opportunity Employer that does not discriminate in employment based on race, color, creed, age, sex, national origin, physical or mental handicap, ancestry, marital status, affectional or sexual orientation, military service, or any other characteristic protected by law. If you require assistance to complete this form or to participate in an interview, please let us know.

Position Desired

Applicant Must Complete

Position Applied For: Date Available to Start:

Type of Employment Desired: Part Time Full Time Full-time or Part-time Preferred Work Location: Onsite Remote Hybrid

Work Shift: First Shift (Day) Second Shift (Evening) Third Shift (Night) Personal Information

Please note: Print in ink or type. Complete all sections. Last Name: First Name: M.I.

Street Address: City: State/Zip

Home Phone: Alternate Phone:

E-mail Address:

Do you have a valid Driver’s License? Yes No Class: CDL? Yes No Do you have relatives working for Pacer Staffing LLC? Yes No; If Yes- Employee’s Name Have you ever served in the military? Yes No Do you speak any other language(s)? Are you legally authorized to work in the United States? Yes No Pursuant to the immigration reform and control act of 1986, all applicants, who are offered employment, must produce documents, which establish their identity and authorization for employment in the United States. These documents must be produced no later than seventy-two hours after commencement of employment. You will be 1445 City Ave, Ste 10B, Wynnewood, PA 19096

w w w . p a c e r s t a f f i n g . c o m 215 - 6 6 6 - 0 0 1 2 i n f o @ p a c e r s t a f f i n g . c o m required to sign INS Form I-9 (issued by the federal government) verifying, under oath, your employment authorization.

Do you now or in the future require sponsorship for employment visa status (e.g., H-1B visa status)? Yes No Have you signed any non-compete or non-solicit agreement with any other employer that might restrict you from working for this company? Yes No If Yes, (You may be required to furnish a copy of the agreement.)

Can you perform the essential functions and responsibilities of the position for which you are applying? Yes No

If not, explain:

Do you require any special accomodation to perform required duties? Yes No If yes, explain:

Have you ever been terminated from employment or asked to resign by an employer? Yes No If yes, please provide company names and details

Have you ever worked for Pacer Staffing LLC? Yes No If so, give date(s) of employment and position(s) held: Do any of your relatives work for Pacer Staffing LLC? Yes No If Yes, State their name & Relationship with you:

List any current licenses, certifications, or registrations required for the position for which you are applying. Include date received.

Have you ever been convicted, found guilty, or accepted deferred adjudication or similar agreement with the court for any crime or driving offense(s) other than a minor traffic violation in the last 10 years? Yes No If yes, written documentation must be provided about criminal offenses from the clerk of court in the county in which the conviction was made, and about any driving offenses other than minor traffic violations from the motor vehicles office.

(Note: Disclosures of convictions does not automatically disqualify you from employment consideration.) You must provide at least three current reference letters and/or the name of individuals with whom a reference interview can be conducted. Please give the full name, mailing address, and phone number of three references who have knowledge of your background and qualifications in the field.

1.

1445 City Ave, Ste 10B, Wynnewood, PA 19096

w w w . p a c e r s t a f f i n g . c o m 215 - 6 6 6 - 0 0 1 2 i n f o @ p a c e r s t a f f i n g . c o m 2.

3.

Education & Skills

Level of education completed:

High School GED College 0-3 yrs

Associate Bachelor Masters

If degree, specify major:

Software Applications: Typing WPM:

Experience

List last 5 years of work experience

From: To:

Name of Employer:

May we contact? Yes No

Address:

City:

State/Zip:

Supervisor’s Name:

Phone Number:

Title and Duties Performed:

Reason for Leaving:

Experience

From: To:

Name of Employer:

May we contact? Yes No

Address:

City:

State/Zip:

Supervisor’s Name:

Phone Number:

You may attach a copy of your resume to this application; however, we require that the experience fields be completed on the application.

1445 City Ave, Ste 10B, Wynnewood, PA 19096

w w w . p a c e r s t a f f i n g . c o m 215 - 6 6 6 - 0 0 1 2 i n f o @ p a c e r s t a f f i n g . c o m Title and Duties Performed:

Reason for Leaving:

I understand that in processing my application with Pacer Staffing LLC, an investigation may be made in which information is obtained through personal interviews, and a review of information held by law enforcement or other government agencies. I authorize you to verify my past employment and education, criminal records, motor vehicle records, personal references, and other job-related data provided on this application, or via the interview process. I authorize appropriate individuals, companies, institutions, or agencies to release information, and I release them from any liability because of such inquiries or disclosures. A consumer report may be generated summarizing this information. I further understand and waive my right of privacy in this investigation and release and hold harmless Pacer Staffing LLC from any liability. I agree that any decision to hire me is contingent upon the results of my report and certify that all statements and answers on my application, resume, or interview are true and complete to the best of my knowledge.

I understand that if any statements are false or that if information has been omitted, this will be cause for disqualification and immediate termination of my employment. If employed, I further authorize Pacer Staffing LLC to check my credit, conviction records, and other items listed above as needed, on a continuous basis as it relates to my employment. I am granting Pacer Staffing LLC an authorization to release confidential medical information upon the request from Pacer Staffing clients while I am actively working at the client’s facility and /or during the profiling, credentialing, and placement processes.

SIGNATURE OF APPLICANT DATE

Contact this candidate