PRE-APPLICATION QUESTIONNAIRE & APPLICATION FOR EMPLOYMENT 1. 2. 3. 4. 5. 6. 7. Are you telephone accessible? Yes No Do you have reliable transportation?

n? Yes No Do you have your I-9 (work status) information? Yes No (Drivers License, State Issued Picture ID, Social Security Card, Birth Certificate, etc) What job(s) are you applying for?___________________________________ _ What area of town are you willing to work?____________________________ _ Are you willing to take a drug screen for illegal use according to our policy? Yes No Will you release your background information inclusive of criminal records? Yes No Days and Hours Available: Monday to Tuesday to Wednesday to Thursday to Friday to Saturday to Sunday to Date PLEASE PRINT INFORMATION BELOW Last Name Address First Name City Middle Name County State Last 4 digits of SSN Zip Code

Signature of Applicant

Are you legally eligible for employment in this country? Yes No If you are under 18, and it is required, can you furnish a work permit? Yes No Have you ever been employed here before? Yes No If yes, give dates and positions: Telephone Date available for work: Answering machine Yes No Alternate contact telephone numbers: Work Cell Pager Email Transportation: Own Vehicle Share Vehicle Bus Yes No If yes, please explain Short term temp Long term temp Part time/perm Full time/perm

Able to work: Day (1st shift) Eve (2nd shift) Night (3rd shift) Weekend days Weekend nights

Yes

Sometimes

Never

Smoking environment preference: Yes

No

Have you ever been convicted of a crime other than a traffic offense? IN CASE OF EMERGENCY CONTACT:

Name Relationship Address Telephone Number DRUG SCREEN AUTHORIZATION AND CONSENT: I hereby authorize and give full permission to have Employment Plus, Inc. and/or their medical company physician send a specimen of my urine and/or blood to a laboratory for screening test using S.A.M.H.S.A. standards for the presence of illegal drugs. I will hold all parties concerned harmless, meaning I will not sue nor hold responsible for any alleged harm to me or interfering with my obtaining a job or continuing employment due to not submitting to the tests or as a result of the test. This includes, but is not limited to, possible clerical or laboratory error. This policy and authorization have been explained to me in a language I understand and I have been told that if I have any questions they will be answered about the test. I understand this is a legal binding document which is binding because Employment Plus, Inc. is sending me for the examination and paying for it. I UNDERSTAND EMPLOYMENT PLUS, INC. WILL REQUIRE A DRUG SCREEN TEST WHENEVER AN ON-THE-JOB ACCIDENT OR INJURY IS REPORTED IN ACCORDANCE WITH EMPLOYMENT PLUS, INC. POLICY. MY REFUSAL TO SUBMIT TO DRUG TESTING WILL BE GROUNDS FOR TERMINATION. Initials RELEASE OF CRIMINAL RECORDS: I, the undersigned, do hereby authorize Employment Plus, Inc. to examine any and all criminal records including city, state, and federal records for any state. In doing so, I understand that I am waiving my right of confidentiality concerning my criminal history. Initials Date of Authorization Drivers License Number Resident Address Mailing Address (If different from Resident Address) Signature State of Issue of Drivers License Number City/State/Zip City/State/Zip Print Applicants Name Social Security Number

Please list any alias, different name, or maiden name you have held: _____________________________________________________________________________________________ I certify that I have read and understand and will abide by all of the above and aforementioned listed segments that I have initialed on this and the previous page of this Pre-Application Questionnaire & Application for Employment with Employment Plus, Inc. Applicant Signature Interviewer Signature Printed Name Printed Name Last 4 digits of SSN Date
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GENERAL SAFETY RULES: 1. Report an injury to your employer/supervisor immediately. 2. Report any observed unsafe condition to your employer/supervisor. Horseplay is prohibited at all times. 3. 4. The drinking of alcoholic beverages is not permitted on the job or during working hours. Any associate proven to be under the influence of alcohol or drugs while on the job will be terminated. If you do not have current First Aid Training. Do not move or treat an injured person unless there is an immediate peril, such as profuse bleeding or stoppage of breathing. 5. 6. Appropriate clothing and footwear must be worn on the job at all times. 7. Where there exists the hazard of falling objects, an approved hard hat must be worn. 8. You should not perform any task unless you are trained to do so and are aware of the hazards associated with that task. 9. You may be assigned certain personal protective safety equipment. This equipment should be available for use on the job, be maintained in good condition, and worn when required. 10. Learn safe work practices. When in doubt about performing a task safely, contact your supervisor for instruction and training. 11. The riding of a hoist hook, or on other equipment not designed for such purposes, is prohibited at all times. 12. Never remove or by-pass safety devices. 13. Do not approach operating machinery from the blind side; let the operator see you. 14. Learn where fire extinguishers and first aid kits are located. 15. Maintain a general condition of good housekeeping in all work areas at all times. 16. Obey all traffic regulations when operating vehicles on public highways. 17. I understand that riding in or operating company vehicles or using my personal vehicle for business purposes is strictly prohibited unless I am granted specific permission from Employment Plus, Inc. Furthermore, if permission is granted by Employment Plus, Inc., I understand that while operating or riding in company vehicles or using my personal vehicle for business purposes, the vehicles seatbelt shall be worn. 18. Be alert to hazards that could affect you and your fellow associates. 19. Obey safety signs and tags. 20. Always perform your assigned tasks in a safe and proper manner. 21. Do not take shortcuts. The taking of shortcuts and the ignoring of established safety rules is a leading cause of associate injury. I certify that I have read, understand, and will abide by the above listed safety rules. Failure to do so may be grounds for termination and may disqualify my unemployment insurance benefits. Initials VOLUNTARY TERMINATION/HOURLY WAGE REDUCTION NOTIFICATION: I understand that as an Employment Plus, Inc. associate: 1. I am NEVER to walk off an assignment prior to completion of my scheduled shift nor will I leave an assignment without providing Employment Plus a three (3) day notice. If for any reason I must leave the assignment prior to the scheduled completion of the workday, I will contact Employment Plus, Inc. AND communicate my reason(s) for doing so to my assigned supervisor. 2. I am to call Employment Plus, Inc. AND the client for whom I am working prior to the start of my scheduled shift if I am going to be tardy or absent. I am to contact Employment Plus, Inc. within three (3) days of the completion of my assignment or termination, voluntary or otherwise, from the client for whom I am working. 3. By signing below I acknowledge that I fully understand and accept the aforementioned policies. Furthermore, I understand, agree and accept that my failure to comply with any of these policies as set forth by Employment Plus, Inc. will constitute my VOLUNTARY TERMINATION from Employment Plus, Inc.s employment and will result in my pay rate being reduced to MINIMUM WAGE* for the workweek during which the policy violation occurs and may also jeopardize my UNEMPLOYMENT INSURANCE BENEFITS. Initials * Amount to be no less than STATE MINIMUM WAGE as determined by the state in which the job is performed. The policies contained on this application apply to Employment Plus unless State or Local Law dictates otherwise. If State or Local Law/Statutes conflict with information contained on this application, Employment Plus will comply with all State or Local Laws/Statutes. CONSENT TO RELEASE PAYCHECK (OPTIONAL): I authorize Employment Plus, Inc. to release my paycheck to any of the people listed below. Initials Print Name: Print Name: Print Name: Print Name:

Policies and procedures checklist: 1. I am telephone accessible and I have reliable transportation. 2. I understand that I am expected to complete any job assignment that I accept. If I do not complete the assignment then Employment Plus, Inc. can assume that I have voluntarily quit. 3. I understand that I am an associate of Employment Plus, Inc. and only I or Employment Plus, Inc. can terminate my employment for any reason or no reason at all. When an assignment ends I must report to the Employment Plus, Inc. office for my next assignment. Failure to do so or to accept my next job assignment will indicate that I have voluntarily quit and I will not be eligible for unemployment benefits. 4. Employment Plus, Inc. has a very strict NO DRUG POLICY, and I have signed a consent form to submit to drug testing. I understand that my failure to comply with this agreement will be grounds for my immediate termination. 5. Once I have accepted a job, I must report to the Employment Plus, Inc. office to pick up a time sheet unless instructed otherwise by Employment Plus, Inc. Unless special arrangements have been made, I understand Employment Plus, Inc. will not recognize or pay for any hours worked by an associate in the absence of an individual time ticket signed by both the client and the associate. 6. If for some unexpected reason, such as an emergency or illness, I cannot make it to work or will be late, I will contact Employment Plus, Inc. as soon as possible so you can call the client and/or find a replacement. My failure to do so may be grounds for dismissal and/or indicate that I have quit. 7. If I sustain an injury on the job, I will inform the client and Employment Plus, Inc. immediately after the accident. Employment Plus, Inc. will coordinate with the client and myself the proper procedure for treatment and reporting of the accident. 8. I understand and will comply with Employment Plus, Inc. safety rules, regulations, and hazardous communication program explained to me in the Employment Plus, Inc. orientation. 9. Employment Plus, Inc. pays its associates once a week. Employment Plus, Inc.s pay period starts on Monday and ends on Sunday. My check will be ready after 8:00 a.m. the Friday following the week worked (unless other arrangements have been made). 10. I understand that in order to be paid in a timely manner, time tickets must be turned in no later than 12:00p.m. each Monday following the week worked, NO EXCEPTIONS. Any late tickets will not be paid until the following payroll week (next week). I have read and fully understand the above statements regarding Employment Plus, Inc. policies and procedures and agree to the same. I understand that failure to comply with these policies and procedures could lead to my termination and may jeopardize my Unemployment Insurance Benefits. Initials I certify that I have read and understand and will abide by all of the above and aforementioned listed segments that I have initialed on this and the previous page of this Pre-Application Questionnaire & Application for Employment with Employment Plus, Inc. Applicant Signature Interviewer Signature Printed Name Printed Name Last 4 digits of SSN Date
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WORK EXPERIENCE: Industry/Occupations # of Years Accounting/CPA Advertising/Marketing/PR Broadcast Media Business Services Casinos & Gambling Communications Services Construction-All Construction Services Consumer Products Cust. Serv./Call Center Energy Engineering Financial Services Government Agencies Healthcare Hospitality/Tourism Insurance Legal Mail Order & Catalog Manufacturing Mfg-Automotive Mfg-Chemical Mfg-Food Mfg-Medical Mfg-Metal Mfg-Paper Mfg-Plastic Mfg-Printing/Publishing Mfg-Rubber Mfg-Wood Military/Defense Personal Services Printing & Publishing Professional Consulting Real Estate Recreational Activities Rental & Leasing Restaurants Sales Schools/Education Specialty Services Accounting Acct-AP/AR Acct-Billing Acct-Bookkeeping Acct-Collections Acct-CPA Acct-Credit Acct-General Ledger Acct-Inventory Acct-Payroll Acct-S/W-AccPac Acct-S/W-Great Plains Acct-S/W-Mass 90 Acct-S/W-Peachtree Acct-S/W-QuickBooks Clerical C-Administrative Assistant C-Bank Teller C-Banking (General) C-Dictaphone C-Executive Assistant C-Multi-Line (A) 1-5 C-Multi-Line (B) 6-10 C-Multi-Line (C) 11-15 C-Multi-Line (D) 15 + C-Switchboard C-Telemarketing Industry/Occupations # of Years C-Transcribing Clerical-Contd C(S)-Leasing C(S)-Library C(S)-Real Estate C(S)-Staffing Computer CMP-.NET CMP-Adobe Acrobat CMP-Adobe Illustrator CMP-Adobe InDesign CMP-AS 400 CMP-Auto Cad CMP-C/C++ CMP-Cobol CMP-Cold Fusion CMP-Corel PhotoHouse CMP-Dreamweaver CMP-File Transfer Protocol CMP-Flash CMP-Fox Pro CMP-Java CMP-LAN CMP-LOTUS CMP-Macintosh CMP-Macintosh 4D CMP-Novell CMP-One Write Plus CMP-Oracle CMP-PageMaker CMP-Paradox CMP-PhotoShop CMP-Platinum CMP-Quark CMP-Quattro Pro CMP-Southware CMP-SQL CMP-Unix CMP-Visual Basic CMP-WAN CMP(M)-Access CMP(M)-Outlook CMP(M)-Publisher Engineering Eng-Air Quality Eng-Chemical Eng-Civil Eng-Electrical Eng-Engineer Eng-Environmental Eng-Industrial Eng-Maintenance Eng-Materials Eng-Mechanical Eng-Mining Eng-Nuclear Finance FIN-Budget FIN-Business FIN-Financial Industrial I-Assembly (Electrical) I-Assembly (General) I-Assembly (Medical) I-Caliper I-Cleaning (Domestic) I-Cleaning (Industrial) Industry/Occupations # of Years I-Die Casting I-Die Cutting Industrial Cont I-Die Making I-Drill Press I-Dry Cleaning I-Drywall I-Food Service I-Forklift (Certified) I-Forklift (General) I-General Construction I-General Industrial I-Housekeeping I-Inventory I-Janitorial I-Landscaping I-Lathe I-Loading (1-10 lbs) I-Loading (11-20 lbs) I-Loading (21-50 lbs) I-Loading (50+ lbs) I-Machine Operator I-Machining (General) I-Masonry I-Material Handling I-Packaging I-Painting (General) I-Painting (Industrial) I-Plastic (Extrusion) I-Plastic (Injection Molding) I-Printing Press I-Punch Press I-Screen Printing I-Shipping/Receiving I-Sorting I-Warehouse (General) I(S)-Auto Body I(S)-Auto Detailing I(S)-Auto Mechanic I(S)-CDL Class A I(S)-CDL Class B I(S)-CNC Lathing I(S)-CNCN Machining I(S)-Commercial I(S)-Communications Equip I(S)-Computer I(S)-Diesel I(S)-Electrical I(S)-Engine I(S)-Heavy Equipment I(S)-Industrial Equip I(S)-Line Leader I(S)-Maintenance Tech I(S)-Management I(S)-Office Equip I(S)-Operations I(S)-Quality Control I(S)-Scheduler I(S)-Supervisor I(S)-Team Leader I(S)-Tool & Die Making I(S)-Welding (Arc) I(S)-Welding (Gas) I(S)-Welding (Mig) I(S)-Welding (Oxygen) I(S)-Welding (Stick) I(S)-Welding (Tig) Industry/Occupations # of Years

Language Lang-Burm/Engl Bilingual Lang-Bumese Only Lang-Indian Only Lang-Indian/Engl Bilingual Lang-Jap/Engl Bilingual Lang-Japanese Lang-Rus/Engl Bilingual Lang-Russian Only Lang-Span/Engl Bilingual Lang-Spanish Only Legal LGL-Legal Assistant LGL-Legal Clerk LGL-Legal Secretary LGL-Paralegal Medical Med-Medical Billing Med-Medical Secretary Med-Medical Transcription Sales SLS-Auto SLS-Computer/Equipment SLS-Engineer SLS-Executive Services SLS-Industrial SLS-Insurance SLS-Pharmaceutical SLS-Real Estate SLS-Route SLS-Technical Technical/Professional T/P-Accounting T/P-Advertising T/P-Application T/P-Attorney T/P-Bar/Restaurant T/P-Blueprint Reader T/P-CAD Drafter T/P-Computer T/P-Corporate Training T/P-Data T/P-Graphics T/P-Human Resources _______ T/P-Industrial Hygiene _______ T/P-Information Technology T/P-Insurance T/P-Management (Executive) T/P-Management (Industrial) T/P-Marketing _______ T/P-Mortgage Processor T/P-Project T/P-Proofreading/Editing T/P-Public Relations T/P-Public School T/P-Research & Development T/P-Risk Management T/P-Safety Coordinator T/P-Software T/P-Systems T/P-Teacher T/P-Technical Writing T/P-Telecommunications T/P-Web
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PLEASE COMPLETE THE FOLLOWING INFORMATION

PREVIOUS EMPLOYMENT Most recent employer Telephone: Dates Employed: From Supervisor: to Job Title/Duties Performed: End Reason for Leaving: _

Hourly Rate/Salary: Starting

Second most recent employer Telephone: Supervisor:

Dates Employed: From

to

Job Title/Duties Performed: End Reason for Leaving: _

Hourly Rate/Salary: Starting

Third most recent employer Telephone:

Dates Employed: From Supervisor:

to

Job Title/Duties Performed: End Reason for Leaving: _

Hourly Rate/Salary: Starting

Education: Circle the highest grade completed: 7 8 9 10 11 12 13 14 15 16 16+ GED

High School__________________________________________________________________________________________________________________________ Name City/State Graduate? Degree College _________________________________________________________________________________________________________________________ Name City/State Graduate? Degree Other ___________________________________________________________________________________________________________________________ Name City/State Graduate? Degree

Personal Reference
Please list two personal References with whom You have worked: Name Name Address Address Telephone Number Telephone Number

PLEASE READ: I authorize you to check my references regarding past employment, I agree to contact you after each assignment is completed, to check if other work is available. If I do not contact you, you can assume that I am not available for work. I understand Employment Plus utilizes an auto dialer program and I provide express consent to be contacted at the phone number provided regarding job assignments, emergency notifications, and other messages sent by Employment Plus. SIGNATURE______________________________________________________________________________________________________________Date______________________ We are an equal opportunity employment company, dedicated to a policy of non-discrimination in the terms and conditions of employment on the basis of race, sex, religion, color, national origin, citizenship, veteran status, non-job-related disability or handicap of any kind, veteran status, genetic information, or any other protected class as defined by state or local ordinances.

I hereby declare that all statements contained in this application are true and correct and understand that false or inaccurate information in the application will be the basis for termination. I hereby authorize Employment Plus to investigate my background inclusive of criminal records and verify this information. I understand that if employed, my employment will not be for any fixed period of time and may be terminated by Employment Plus at any time. I also authorize Employment Plus to release the information contained herein and its findings and work history of my employment to other firms or persons upon request. I also understand and agree that I may be expected to work on a wide variety of job assignments and agree to accept assignments for which I am qualified as they become available. I also understand my failure to report to Employment Plus for work will indicate I have quit. I also agree to submit to a drug screen upon request or as specified in Employment Plus' substance abuse policy. PLEASE INITIAL: _____________ I certify that I have read and understand and will abide by all of the above and aforementioned listed segments that I have initialed on this and the previous page of this Pre-Application Questionnaire & Application for Employment with Employment Plus, Inc. Applicant Signature Interviewer Signature Printed Name Printed Name Last 4 digits of SSN Date
Page 4 Revision Date: 6/2010

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