Interview: ______________________

Notes: (C) _____________________

Test Results:
__________________________
__________________________
__________________________
__________________________

Notes: (A) _____________________

Notes: (R) _____________________
Notes: (E) _____________________

Appointment Date / Time //

Referred to QualStaff by:

Position Applying for:

Last Name

First Name

Middle

Social Security #

Home Phone #

Street Address

City

State

Zip Code

Email Address

Cell Phone #

Emergency Contact #1

Phone #

Emergency Contact #2

Phone #

Work Interest: (Mark an X in boxes that may apply)

F/T

P/T

Temporary

Days Available: M

Area City Preferred:

Available Start Date:

Long Term

Th

Short Term

Su

Temp to Hire

Work Hours Available:

Direct Hire

Commute: (Time or Miles)

Comments:

Work Preferences:

Pace: Fast

Moderate

Personal Strength:

Slow

Style: Autonomous

Interactive

Team environment

Income Desired

Hourly:

Salary:

(MINIMUM REQUIREMENTS)

Education (Enter Y for Yes and N for No)

High School Diploma/GED?

GPA

Trade School?

Professional Training/Certifications:

College Degree?

College Attended:

Graduate Degree?

GPA

In Progress?

GPA

School Name:

College Attended:

Work History: (Please list your most recent employer first)

Updated 11/15/06

Employers Name & Address

Your Position Title

Direct Supervisor

Phone #

Reason For Leaving

Your Position Responsibilities

Your Salary (Hourly or Annually)

$

Interviewers Notes

Dates of Employment:
From:
To:

Employers Name & Address

Your Position Title

Direct Supervisor

Phone #

Reason For Leaving

Your Position Responsibilities

Your Salary (Hourly or Annually)

$

Interviewers Notes

Dates of Employment:
From:
To:

Employers Name & Address

Your Position Title

Direct Supervisor

Phone #

Reason For Leaving

Your Position Responsibilities

Your Salary (Hourly or Annually)

$

Interviewers Notes

Dates of Employment:
From:
To:

References Name

Title

Company

Address/City/State/Zip Code

Phone #

Background Information
1) Were you known to any employer, school or reference by another name?
2) Are you at least 18 years of Age?

Yes

Yes

No

No

Updated 11/15/06

3) If employment is offered, can you submit verification of your legal right to work in the United States?

Yes

No

Yes

No

Yes

No

Yes

No

a reservist or guardsman.)
9) Have you ever been discharged from the armed service under other than honorable conditions? You may omit

Yes

No

any such discharge changed to honorable by a Discharge Review Board or similar authority.

Yes

No

4) Have you ever been dismissed or forced to resign from any employment?

Yes

No

If yes, explain:

5) Have you ever been dismissed or forced to resign from any employment for reasons that involved dishonesty
or breach of trust (including but not limited to shoplifting, discount abuse, cash handling, robbery, embezzlement,
theft, forgery, perjury, tax evasion, falsification of Company documents including timecards, etc)?
If yes, explain:

6) Have you ever been convicted of a felony? (Do not identify any felony conviction for which the record has
been judicially ordered sealed, expunged, or statutorily eradicated).
If yes, explain:

7) Have you ever been convicted of a misdemeanor? (Do not answer "yes" if the conviction record has been
judicially ordered sealed, expunged, or statutorily eradicated. Do not answer "yes" if probation for the conviction
was successfully completed or discharged and the case was judicially dismissed under Penal Code 1203.4. Do not
answer "yes" if your conviction was for a misdemeanor marijuana conviction and is more than 2 years old).
If yes, explain:

8) Have you ever served on active duty in the US military service? (Exclude tours of active duty for training as

If yes, explain:

As an equal opportunity employer, QualStaff Resources does not discriminate in hiring or terms and conditions of employment because of an
individual's race, color, sex, national origin, religion, age, disability, or any other legally protected basis. In consideration of my employment, I
agree to conform to the rules and regulations of QualStaff Resources. I understand that, as a matter of Company policy, every aspect of my
employment relationship with QualStaff Resources is on an at-will basis, meaning that I or QualStaff Resources may terminate my employment
at any time, for any reason, with or without cause. As part of this at-will policy, I understand that QualStaff Resources expressly reserves its
inherent authority to manage and control the business enterprise and to exercise its sole discretion to determine all issues pertaining to my
employment as an Associate of QualStaff Resources. I further understand that any agreement, written or verbal, made contrary to the foregoing
will not be valid without written authorization by the Director of Operations of QualStaff Resources and me.
Upon accepting employment, I will be provided with an Orientation Packet. I further acknowledge my understanding that the benefits, policies,
and programs stated in the Orientation Packet are provided at Company discretion and may be changed or eliminated at any time, except the
policy of at-will employment. If employed, it shall be my responsibility to familiarize myself and follow all Company policies and regulations
relating to my employment. In accepting employment I acknowledge that the policies and benefits and other programs as set forth in these
documents are not meant to infer or imply a contract of employment for a specified period between the Company and myself, or otherwise
change the at-will nature of my employment.
I certify that the information contained in this application is correct to the best of my knowledge. I understand that falsification of any
information on this application or a material omission is grounds for immediate dismissal whenever discovered. In considering my application
for employment, I authorize the Company to verify the information set forth on this application and obtain any additional information relating to
my background it may need to assess my suitability for employment. Accordingly, I authorize all persons, schools, companies, corporations,
credit bureaus, and law enforcement agencies to supply the Company with information relating to my background and I do hereby release all
such parties who provide information to the Company from any and all liability for damages that may result from furnishing the same.

Applicant Signature:

Date:

Updated 11/15/06

REFERENCE FORM
TEMPORARY WORK HISTORY
Start
Date

End
Date

Pay
Rate

Start
Date

End
Date

Start
Date

End
Date

Recruiter

Job Title

Client

Supervisors Name & Title

Start
Date

End
Date

Job Title

Client

Supervisors Name & Title

If no, please provide reason.

Would you work on another

assignment at client?

Staffing Service

Recruiter

Job Title

Client

Supervisors Name & Title

Complete Assignment?
If no, please provide reason.

Would you work on another

assignment at client?

Recruiter

If no, please provide reason.

If no, please provide reason.

Staffing Service

Complete Assignment?

Would you work on another

assignment at client?

Staffing Service

If no, please provide reason.

Complete Assignment?

Pay
Rate

Supervisors Name & Title

If no, please provide reason.

Pay
Rate

Client

Complete Assignment?

Pay
Rate

Job Title

If no, please provide reason.

Would you work on another

assignment at client?

Staffing Service

Recruiter

If no, please provide reason.

Updated 11/15/06

NAME:

SOCIAL SECURITY #:

Skill Summary:
Positions Held:

Positions Held (Cont):

Industry Exp (Cont):

Applications Engineer, Senior

Programmer

e-commerce

Applications Engineer, Staff

Product Data Manager

Education

Applications Specialist

Program Administrator

Electronics Manufacturing

Associate Engineer

Program Director

Entertainment

Bus. Applications Engineer, Sr.

Programmer Analyst

Environmental Waste

Bus. Applications Engineer, Staff

Project Engineer

Financial Institution

CAD Administrator

Project Manager

Food Processing

CAD/CAM Designer

QA Engineer

Furniture Manufacturing

Client/Server Programmer

Regulatory Engineer

Government

CNE/CNA

RF Engineer

Government Contracting

Components Engineer, Senior

RF Technician

Healthcare

Computer Systems Supt Analyst

Scheduler

Hotel/Motel

Computer Technician

Senior Engineer

Human Resources

Configuration Manager

Software Documenter

Industrial Manufacturing

Consultant

Software Engineer

Information Technology

Contract Administrator

Software Test Engineer

Insurance

Data Analyst

Systems Administrator, Assoc.

Investment Company

Database Programmer

Systems Administrator, Senior

Legal Services

DBA/Database Administrator

Systems Analyst

Lumber & Wood Manufacturing

Design Engineer

Systems Manager

Manufacturing

Desktop Publisher

Systems Test Engineer

Medical

Director of Manufacturing

Technical Editor

Metal Fabrication

Document Control Manager

Technical Illustrator

Mining

Drafter

Technical Support Analyst

Mortgage Companies

e-commerce Administrator

Technical Support Manager

Motor Freight Transportation

Editor

Technical Support Specialist

Non-Profit

Electrical Engineer

Technical Writer

Oil & Gas

Electronic Technician

UNIX Administrator

Paper Products Manufacturing

Engineering Aide

VP Engineering

Pharmaceutical/Biotech

Engineering Director

VP Quality Assurance

Plastic Manufacturing

Engineering Intern

VP Technology

Printing & Publishing

Engineering Manager

Web Developer

Public Accounting

Functional Analyst

other:

Public Utility

Graphic Artist

Railroad Transportation

Hardware Engineer

Real Estate

Help Desk

Restaurant

HRMS Analyst

Industry Experience:

Retail

Information Systems Director

Advertising

Telecommunication

Information Technology Director

Aerospace

Water Transportation

Logistics Specialist

Agricultural

Wholesale Distribution

Manufacturing Engineer

Air Transportation

other:

Manufacturing Manager

Amusement Park

Mechanical Designer

Apparel Manufacturing

Mechanical Engineer

Architectural

Updated 11/15/06

Multimedia Specialist

Automotive

Network Administrator

Beverages

Network Analyst

Communications

Network Engineer

Computer Software

PC Network Technician

Construction

Planner

Credit Agencies

Technical Experience:

Professional Certifications:

Networking/Op. Systems:

AMPS

A+

ARCServe 6.0

Analog IC Design

ASE

DOS

Apache WebServer

ASNT

Groupwise

AutoCAD

CE

LAN

Avalon

Certified Internet Webmaster

Lantastics

Baseband Chips

CNE/CNA

Linux

Bipolar Technology

CSE

MacIntosh

Board Level Design

Ericsson

Mail Server

CDMA Technology

HyCurve

MS Back Office

Cisco Routers

IBM

MS Back Office Small Bus.

CMOS Technology

Informix

MS Exchange

Control Systems

Linux Professional Institute

MS Exchange

CORBA

Lucent Technologies

MS Networking

CVS

MCSD

MS Proxy Server

Educational Software

MCSE

MS SMS

Ethernet TCP/IP

MCSE+I

MS SNA

Firewalls

Microsoft

MS Windows 2000

Frequency Synthesis

Network+

MS Windows 98

FTP

Novell

MS Windows NT 3.51

Gaming

other:

MS Windows NT 4.0

GMP

MVS

GPS

NetWare 3.0

GSM

Novell Netware

HSPICE

OS/2

IF

PC-Clone

Image-Recognition

Peer-to-Peer

Intralink

Foreign Languages:

Sun Solaris

IPX

Cantonese

TCP/IP

ISO 9000

Dutch

UNIX

JEDEC Standards

German

WAN

Just-In-Time (JIT) Systems

Hindi

Web Hosting

KANBAN

Indonesian

other:

Microbrowsers

Italian

Mixed Signal ATE

Japanese

MMI Programming

Korean

MVS Build

Mandarin

NFS

Portuguese

Hardware:

NIS

Spanish

AS400

Optic

Tagalog

Deck Alpha

Perforce

Vietnamese

IBM & Compatibles

PLL Design

Vietnamese

Macintosh

Pro/E

other:

Main Frames

QS 9000

MiniComputers

RDBMS

other:

RF

SNMP

Updated 11/15/06

Spectre

Telnet

Virtual Reality Apps.

Voice-Recognition

Windows API

Wireless Broadband

other:

Languages/Platforms:

Database Experience:

Spreadsheet Software:

ASP

Access 2000

Excel 2000

Ansii SQL

Access 97

Excel 97

Assembler

Adabas

Lotus 123

Avalon

Btrieve

Lotus 97

Basic

DB2

Lotus DOS

BB

Dbase III

QuatroPro 6.0

Dbase IV

other:

C++

FileMaker Pro 4.0

COBOL

Foxpro

Cold Fusion

Informix

COM/COM+

Lotus Approach 97

Graphics/Presentations:

CSP

MS Exchange Server

Corel Draw

DB Reporter

MS Internet Info Server

Display Write IV

DCOM

Oracle

First Publisher

DHTML

OS/2 Server

FrameMaker

FORTH

Paradox

Harvard Graphics

Fortran

SQL Server 7.0

Illustrator

Front Page 2000

Sybase

MacDraw

Front Page 97

other:

MS Project Manager

HDML

PageMaker

HTML

Paint Shop

Informix

PhotoShop

JAVA

Word Processing Software:

PowerPoint 2000

Javascript

AmiPro

PowerPoint 97

Ladder Logic

Lotus WordPro

Quark

MIPS

MS Word 2000

Visio

MS FCL

MS Word 97

other:

MS Visual InterDev

MS Works

Natural

Word Perfect 7.0

Netscape Composer

Word Perfect 8.0

Oracle

other:

Misc Software:

OS/2 Rexx

McAfee Virus for Windows

Pascal

MS Outlook

PL/1

MS Project

PLC

Norton Utilities

QMF

other:

Sequential Function Chart

Shell Scripts (csh, ksh, perl, etc.)

SPARC

Job Search Engines:

SQL

list below primary job search sites:

Resume Postings:
list below where you post your
resume:

Structured Text

Visual Basic 5.0 and above

Visual Basic for Applications

Visual C

Updated 11/15/06

Visual C++

Visual Fox Pro

Visual J++

Visual Java

Winsock

WML

XML

XSL

other:

Updated 11/15/06