Employment Application

Employment Application



    Please list three professional references.

    Previous Employment

    Military Service

    Emergency Contacts

    Disclaimer and Signature

    I certify that my answers are true and complete to the best of my knowledge.

    If this application leads to employment, I understand that false or misleading
    information in my application or interview may result in my release.

    Background Screening Consent

    Applicant should complete all relevant information and sign and date the form.

    I, *, hereby authorize PIC'D Staffing Services, LLC and/or its agents to make an independent investigation of my background, references, character, past employment, education, credit history,
    adult criminal or police records, and motor vehicle records including those maintained by both public and private organizations and all public records for the purpose of confirming the information contained on my Application and/or obtaining other information which may be material to my qualifications for service now and, if applicable, during the tenure
    of my employment or service with PIC'D Staffing Services, LLC.

    I release PIC'D Staffing Services, LLC and its agents and any person or entity, which provides information pursuant to this authorization, from any and all liabilities, claims or law suits in regards to the information obtained from any and all of the above referenced sources used. The following is my true and complete legal name and all information is
    true and correct to the best of my knowledge:

    (Please circle any of the following states in which you have lived: CA, CO, DE, LA, MA, SD, VT, WV, WY)

    *NOTE: The above information is for identification purposes only, and is in no manner used as qualifications for employment, internship, or service as a volunteer. PIC'D Staffing Services, LLC abides by all applicable state and federal employment laws.


    Applicant should complete all relevant information and sign and date the form.

    I,*, understand that pursuant to PIC'D Staffing Services, LLC's Policy for a Drug and Alcohol-Free Workplace, I am being to drug screening test.

    I hereby consent to submit to urinalysis, breath, blood, and/or other tests as shall be determined by PIC'D Staffing Services, LLC for the purpose of determining the use of illegal drugs.

    I agree that testing laboratory, may collect these specimens for these tests and may test them or forward them to a testing laboratory designated by the Company for analysis. I further agree to and hereby authorize the release of the results of said tests to the Company.

    I understand that it is the current illegal use of drugs and/or abuse of alcohol that prohibits me from obtaining employment with the Company.

    I am unaware of any medical condition that would indicate that either the screen or physical examination might endanger my physical health.

    I agree to hold harmless the Company and its agents (including the above named physician or clinic) from any liability arising in whole or part out of the collection of specimens, testing, and use of the information from said testing in connection with the Company's consideration of my continuing employment.

    I agree that a reproduced copy of this consent and release form shall have the same force and effect as the original.

    I have carefully read the foregoing and fully understand its contents. I acknowledge that my signing of this consent and release form is a voluntary act on my part and that I have not been coerced into signing this document by anyone.


    NOTICE TO OFFEREES: In compliance with the Americans with Disabilities Act of 2008(ADA), you have received a conditional offer of employment. This medical history statement is of all offerees. The answers to the medical history statement and any medical examination will be kept confidential and in separate files in compliance with the ADA requirements. The job offer, which you have received, is conditioned upon satisfactory completion and review of this medical questionnaire and any medical examination or follow up.

    GINA DISCLOSURE: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. "Genetic information" includes an individuals family medical history, the results of an individuals or family members genetic tests, the fact that an individual or an individuals family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individuals family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

    EMPLOYEE AFFIRMATION: I here with affirm that the employer has made me an offer of employment, conditioned on, among other things, the satisfactory completion of this questionnaire. The purpose of this inquiry is as follows: (1) to determine whether I currently have the physical qualifications necessary to perform the essential functions of the job that has been offered; (2) to determine what accommodations, if any, may be necessary for me to perform the essential functions of the job; and (3) to determine whether I can perform the essential functions of the job without posing a significant direct threat to the health and safety of myself and others. This information will be kept strictly confidential in a separate medical file, apart from my personal file. I hereby affirm that the questions in the medical questionnaire have not been asked of me by anyone with the employer until after I have signed this statement and been offered a conditional job.The conditional job duties
    have been adequately described to me, and I have had an opportunity to ask questions regarding the duties.

    1.Have you ever had or been treated for any of the following conditions or diseases?

    My signature certifies that all facts and representations made by me are true, accurate and made willingly and intentionally.


    Having met the eligibility requirements, you are being offered the opportunity to enroll in health coverage offered by PIC'D Staffing Services, LLC's. You have the right to decline, or waive coverage. If you did waive coverage for yourself, you may not cover dependents under the Employer's health plan.

    Note that if you waive coverage considered affordable and minimum essential under the patient Protection and Affordable Care Act (ACA), you will not qualify for government credits and subsidies to purchase individual health insurance on the Marketplace.

    The decision to waive coverage has consequences for you. For example:

    • If you waive this coverage and do not obtain coverage on your own, you will be subject to a penalty under the individual responsibility requirement of the ACA.

    • If you waive coverage and you cannot enroll in PIC'D Staffing Services, LLC's health plan until the next open enrollment, unless you experience a qualified change in status. Examples include if you are covered under another plan but that coverage is lost, or if you gain a new dependent through birth, adoption, or marriage. However, you must request to enroll in your plan within 30 days of the quilified change in status. If you missed the 30-days enrollment deadline, you must wait until open enrollment.

    I acknowledge that the Employer has offered me affordable minimum essential coverage under the ACA, for the periad from 01/01/2018 to 12/31/2018. I have read the above and I understand the consequences of my waiver of coverage.


    I acknowledge that I have received a copy of the Company's Temporary Employee Handbook,which contains important information on the Company's policies, procedures, safety, and training. I understand agree that the policies described in the handbook are intended as a guide only and do not constitute a contract of employment. I specifically understnad and agree that the employment relationship between the Company and me is at-will and can be terminated by Company or me at any time, with or without cause or notice.

    furthermore, the Company has the right to modify or alter my position, or impose any form of discripline it deems appropriate at any time. Nothing in this handbook is intended to modify the Comapany's policy of at-will employment. The at-will employment relationship may not be modified except by specific written agreement signed by me and the Company's Chief Executive Officer.

    This is the entire agreement between the Company and me regarding this subject. All prior or contemporaneous inconsistent agreements are superscded. I understand that, with the exception of the at-will employment policy,the Company reserves the right to make change to its policies,procedures and benefits at any time at its discretion. I further understand that the Company reserves the right to interpret its policies or to vary its procedures, as it deems necessary or appropriate.

    You must read and understand all the components of this handbook. Before signing, if there are any areas, you do not understand, please have the Company's local brance office explain them to you. By signing this handbook, I acknowledge that I have read this handbook and that it has been explained to me. Any safety and training materials in this handbook have also been reviewed with me.


    Problem Solving Arbitration Agreement

    In the unlikely event of a dispute or claim against PIC'D STAFFING(the "Company"), its employees or agents having anything to do with my application for employment, or separation from employment with the Company, I and the company agree that all such claims will be settled by binding arbitration by a ncutral arbitrator under the employment
    dispute rules of the American Arbitration Association (AAA). This means that I and company give up the right to have dispute decided in court by a judge or jury. Instead, it will be resolved by an impartial arbitrator whose decision is final. Examples of dispute that I and Company agree to submit to arbitration include, but are not limited to, claims for discrimination based on disability, religion, national origin, race, age, sex, or any other basis; sexual or other harassment; wrongful termination; breach of premise; defamation; and all other charges related to any spect of my employment relationship with the Company. Unless otherwise provided by law, party shall be responsible for its own attomeny's fees and costs. The arbitration shall be held at a mutually convenient location in the city where I'm employed. The arbitrator's fees shall be paid for by the Company. By law,claims involving worker's compensation and unemployment insurance, may not be submitted to arbitration, and therefore are not covered by this agreement.