TOP SHELF STAFFING, LLC

NAME / NOMBRE *

Legal name as it appears on your ID

First Name

Last Name

PREFERRED LANGUAGE / IDIOMA PREFERIDO

CHECK ONE PLEASE

ENGLISH

SPANISH

PHONE NUMBER / NUMERO DE TELEFONO *

(###)

###

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EMERGENCY CONTACT NUMBER/ CONTACTO DE EMERGENCIA NUMERO *

(###)

###

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SHIFT

1st shift

2nd shift

3rd shift

ARE YOU OVER 18 YEARS OLD? / ES MAYOR DE 18 ANOS? *

YES

NO

ARE YOU AUTHORIZED TO WORK IN THE UNITED STATES? / ES USTED AUTORIZADO PARA TRABAJAR EN LOS ESTADOS UNIDOS *

YES

NO

SKILLS/CERTIFICATIONS - HABILIDADES / CERTIFICACIONES

CHECK SKILLS YOU HAVE AT LEAST 6 MONTHS EXPERIENCE WITH

GENERAL LABORER

SEW ON MACHINE OPERATOR

SERGER OPERATOR

HYSTER DRIVER

AS 400

CREELER

TUFTING MACHINE OPERATOR

MENDER

LEAD PERSON/SUPERVISOR/SHIFT LEAD

MONEY HANDLING/CASHIER

PAYROLL SPECIALIST

ACCOUNTS PAYABLE / RECEIVABLE

BOOKKEEPER

OFFICE ASSISTANT

EXTRUSION OPERATOR

COLOR COMPOUNDER

MAINTENANCE

DRIVER (CDL CERTIFIED)

BOX TRUCK / DELIVERY DRIVER

CONSTRUCTION

ELECTRICIAN

MASONARY

HEAVY EQUIPMENT OPERATOR

CARPENTRY

DID YOU GRADUATE? / TE GRADUASTES?

YES

NO

CONTINUED EDUCATION / EDUCACION CONTINUADA

GED

Some College

Associates Degree

Bachelors Degree

Masters Degree

PhD

RELEASE OF MEDICIAL INFORMATION: I authorize TOP SHELF STAFFING, LLC in the event of an on the job accident to request and obtain records regarding any industrial and / or occupational disease involving myself and TOP SHELF STAFFING, LLC. This is to include, but not limited to, doctor’s reports, nurses notes, follow-up reports, medical bills, test results, etc.. A facsimile or photo static copy of this authorization shall be considered as effective and valid as the original. The release shall be in effect until specifically rescinded by me in writing. I HAVE BEEN FULLY ADVISED THAT IF I AM INJURED ON THE JOB, REGARDLESS OF HOW BAD THE INJURY MAY SEEM, I AM TO REPORT MY INJURY IMMEDIATELY TO MY SUPERVISOR AND TOP SHELF STAFFING. I understand any false or misleading answers to these questions may be a significant reason for the denial of workers compensation benefit and a basis for termination. Also, making false or misleading statements with the purpose of obtaining workers compensation benefits may be punishable with fines and a prison sentence.

I CONSENT

HEALTH QUESTIONNAIRE

This section is to help us understand what kind of position would be best for you and your health. THIS SECTION IS OPTIONAL

Epilepsy / Epilepsia

Diabetes (sugar problems)

Cardiac (heart) disease

Marie Strumpell Disease

Hemophilia or other blood disease

Osteomyelitis

Stiff Joints

Cerebral Palsy

Multiple Sclerosis

Parkinson Disease

Vascular (Circulation) Disorder

Back, head, or knee conditions/pains?

Psychiatric or psychological treatment or evaluation

Any loss of vision

Polio

Muscular dystrophy

Hypoglycemia (sugar problems)

Herniated intervertebral disc

Back surgery

Arthritis

Head injury/concussion

ON THE JOB INJURIES: Should an accident occur while on assignment, I understand a drug and/or alcohol screening will be required **immediately**. I will report my injury to my supervisor and contact Top Shelf Staffing. I consent and authorize my participation in random drug screening, and I agree to hold all parties involved harmless in the event any test may show a positive result. My refusal to submit to the drug and/or alcohol testing requested will be grounds for immediate termination. Should the test results after an accident on the job be negative TOP SHELF STAFFING, LLC agrees to pay all lab fees. Should the test results be positive and/or one of the following occurs, I agree to pay lab fees: • I leave the assignment before the 90-day term unless other arrangements are made • I am released from assignment for cause • Retesting is required because of a diluted specimen • I fail to report to the assignment as agreed *

I CONSENT

DRUG/ALCOHOL SCREENING: I give full permission and authorization to have TOP SHELF STAFFING, LLC and/or their medical physician send a specimen of my urine and/or blood to a laboratory for screening using N.I.D.A standards for the presence of illegal drugs, alcohol, or prescription medication taken without a prescription. I understand that should I fail a drug screen for a substance I cannot provide a prescription for that will result in my immediate termination/disqualification from employment. *

I CONSENT

BACKGROUND SCREENING: I give TOP SHELF STAFFING, LLC permission to run my background for employment purposes. I acknowledge and understand that any violations or charges that may appear on my background WILL NOT DISQUALIFY ME from employment. *

I CONSENT

DRUG AND BACKGROUND CHARGES: Top Shelf Staffing does NOT charge employees out of pocket for their drug screen and background checks. I acknowledge and consent that Top Shelf Staffing will charge me a fee due to costs of drug screening and background checks. I consent the charge will be $60 total and consent to Top Shelf Staffing deducting that fee from my paychecks. *

I CONSENT

PROVISIONAL PERIOD NOTICE: I understand that I am an employee of Top Shelf Staffing, LLC and understand my 90 day provisional period. I am subject to termination should the following occur: poor attendance, inappropriate behavior or comments, poor work performance/quality, harassment, sexual harassment, statements that involve conducting/inciting violence, and physical altercations. I understand, while being a Top Shelf Staffing, LLC employee, I am to bring all absence excuses to the attention of my employer first. I also understand, failing to inform my employer of any reason I am late or out of work could result in my termination. *

I CONSENT