Personal Information
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* First Name
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Middle Initial
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* Last Name
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* Email
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* Daytime Phone
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Night-time Phone
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Present Address
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City
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State
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Zip Code
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Permanent Address
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City
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State
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Zip Code
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Referred By:
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Employment Desired
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Position Desired
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Location
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Date You Can Start
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Salary Desired
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Are You Employed?
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Yes
No
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If so, May we contact your present employer?
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Yes
No
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Education
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High School
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Name/Location of School:
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Degree
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Years Attended
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College
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Name/Location of School:
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Degree
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Years Attended
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Trade or Business School
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Name/Location of School:
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Degree
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Years Attended
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Certifications/Training/Special Skills Related to Position
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US Military or Naval Service
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Rank
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Work Experience(Starting with Most Recent First)
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Dates
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From
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To
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Company
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Address
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Phone
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Immediate Advisor
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Salary
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Start
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Finish
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Position
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Duties
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Reason for leaving
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Dates
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From
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To
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Company
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Address
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Phone
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Immediate Advisor
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Salary
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Start
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Finish
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Position
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Duties
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Reason for leaving
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Dates
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From
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To
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Company
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Address
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Phone
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Immediate Advisor
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Salary
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Start
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Finish
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Position
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Duties
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Reason for leaving
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Dates
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From
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To
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Company
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Address
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Phone
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Immediate Advisor
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Salary
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Start
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Finish
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Position
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Duties
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Reason for leaving
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General
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Are you eligible for employment in the United States?
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Yes
No
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Have you ever been convicted of a felony?
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Yes
No
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If yes, describe offense
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References
Give below the names of three persons not related to you, who know your qualifications.
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1.
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2.
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3.
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Release of Credit Information
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I hereby authorize Coastal HR Group, Inc to make inquire into, investigate, and
examine any and all records that may relate to my current or past credit worthiness;
such information to include (but not limited to) a retail credit report provided
by any of the commercial retail credit reporting companies. I release and hold harmless
each and every person, company or other party that may provide the aformentioned
credit information to Staff USA.
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* Name
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Date
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Privacy Act
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I understand that I may request and will receive a copy of any and all information,
report or other material secured by Coastal HR Group, Inc as a result of any background
check authorized. A copy will be provided to me by Coastal HR Group, Inc (at no
charge) upon my written request.
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* Name
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Date
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Authorization
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"I certify that the facts contained in this application are true and complete to
the best of my knowledge and understand that, if employed, falsified statements
on this application shall be grounds for dismissal.
I authorize investigation of all statements contained herein and the references
and employers listed above to give you any and all information concerning my previous
employment and any pertinent information they may have, personal or otherwise and
release the company from all liability for any damage that may result from utilization
of such information.
I also understand and agree that no representative of the company has any authority
to enter into any agreement for employment for any specified period of time, or
to make any agreement contrary to the foregoing, unless it is in writing and signed
by an authorized company representative."
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* Name
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Date
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Equal Opportunity Employer
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